Abortion Scheduling Template

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Abortion Scheduling Template
Date: __________________
Name: ____________________________________________________________________
Phone #: _________________________________ OK to Leave Message: Tina: Dr.’s Office
nd
2
#: ____________________________________ 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

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