Abortion Scheduling Template printable pdf download

Abortion Scheduling Template

Date: __________________

Name: ____________________________________________________________________

Phone #: _________________________________ OK to Leave Message: Tina: Dr.’s Office

#: ____________________________________ OK to Leave Message: Tina: Dr.’s Office

Cash

Insurance

Medicaid

Insurance Carrier: ________________________________________________

Policy Number: __________________________________________________

Policy Holder: ___________________________________________________

Medicaid #: ______________________________________________________

LMP: ______________ Weeks: ___________________

Positive pregnancy test? YES NO

Appointment Information

Day: _______________________ Date: ________________ Time: __________________

Medication

Aspiration

Unsure

Local Anesthesia

Conscious Sedation

Other:___________

Unsure

Review:

Payment, insurance, fee information. Fee quoted: ________________

Bring a photo ID and your insurance card

Expect to be at the office between 2 to 4 hours

Make sure you have a ride home if you plan on having any sedation

NPO policy reviewed, as appropriate

Wear 2-piece, comfortable clothing

Please arrange for your own childcare

Charge for Rhogam

We will call to confirm your appointment a day or two before (review code)

Participation of support person reviewed

________________________________________________________________

Comments:

___________________________________________________________________________

Staff Initials: _______

TEACH// b.d.i.

Updated 2016

Abortion Scheduling Template