Verification Of Pregnancy And Gestational Age

VERIFICATION OF PREGNANCY AND GESTATIONAL AGE

By Local Health Department

Michigan Department of Community Health

I certify that on ____________ (date) at ________________ (time) at the

________________ health department, the pregnancy of

_____________________ (patient) was confirmed.

At this time, the gestational age of the fetus is ____________________.

____________________________________

____________

Signature of Local Health Department Official

Date Signed

Authority: PA 345 of 2000

Completion: IS REQUIRED, if the patient requests a pregnancy verification and

determination of gestational age in order to fulfill the requirements of the

Informed Consent for Abortion Law, PA 345 of 2000.

Copy Distribution: Patient

Local Health Department

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Parent category: Legal