State Form 55320 - Abortion Consent
Download a blank fillable State Form 55320 - Abortion Consent in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete State Form 55320 - Abortion Consent with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Reset Form
ABORTION CONSENT
State Form 55320 (6-13)
INDIANA STATE DEPARTMENT OF HEALTH – IC 16-34-2-1.1(a)
INSTRUCTIONS: The purpose of this form is to document your voluntary and informed consent for an abortion.
In this form, “abortion” refers to either a surgical abortion or a medication abortion (abortion resulting from an
abortion inducing drug). The completed form is kept by the provider as part of your medical record.
By my signature below, I affirm the following:
1. This form is being completed at least eighteen (18) hours before the abortion.
2. My consent to an abortion is voluntary.
The physician who is to perform the abortion, the referring physician or a physician assistant (as defined in
IC 25-27.5-2-10), an advanced practice nurse (as defined in IC 25-23-1-1(b)), or a midwife (as defined in IC 34-
18-2-19) to whom the responsibility has been delegated by the physician who is to perform the abortion or the
referring physician has informed me orally and in writing of the following:
1. The name of the physician performing the abortion, the physician's medical license number, and an
emergency telephone number where the physician or the physician's designee may be contacted on a
twenty-four (24) hour a day, seven (7) day a week basis.
2. That follow-up care by the physician or the physician's designee (if the designee is licensed under
IC 25-22.5) is available on an appropriate and timely basis when clinically necessary.
3. The nature of the proposed procedure or information concerning the abortion inducing drug.
4. Objective scientific information of the risks of and alternatives to the procedure or the use of an abortion
inducing drug, including:
(a) the risk of infection and hemorrhage;
(b) the potential danger to a subsequent pregnancy; and
(c) the potential danger of infertility.
5. That human physical life begins when a human ovum is fertilized by a human sperm.
6. The probable gestational age of the fetus at the time the abortion is to be performed, including:
(a) a picture of a fetus;
(b) the dimensions of a fetus; and
(c) relevant information on the potential survival of an unborn fetus;
at this stage of development.
7. The medical risks associated with carrying the fetus to term.
8. The availability of fetal ultrasound imaging and auscultation of fetal heart tone services to enable the
pregnant woman to view the image and hear the heartbeat of the fetus and how to obtain access to
these services.
9. The pregnancy of a child less than fifteen (15) years of age may constitute child abuse under Indiana
law if the act included an adult and must be reported to the department of child services or the local law
enforcement agency under IC 31-33-5.
I have been informed orally and in writing of the following:
1. That medical assistance benefits may be available for prenatal care, childbirth, and neonatal care from
the county office of the division of family resources.
2. That the father of the unborn fetus is legally required to assist in the support of the child. In the case of
rape, the information required under this clause may be omitted.
3. That adoption alternatives are available and that adoptive parents may legally pay the costs of prenatal
care, childbirth, and neonatal care.
4. That there are physical risks to the pregnant woman in having an abortion, both during the abortion
procedure and after.
5. That Indiana has enacted the safe haven law under IC 31-34-2.5.
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Il 505-0514 - Application For A Real Estate Limited Liability Company License, Form 505-0341 - Consent To Examine And Audit Special Accounts
Legal
Form Il 505-0335 - Application For A Real Estate Branch Office/form 505-0341 - Consent To Examine And Audit Special Accounts - 2013
Financial
Related Categories
Parent category: Legal