Informed Consent Checklist - Abortion Template printable pdf download

State of Missouri

Department of Health and Senior Services

Informed Consent Checklist - Abortion

I certify that the following information was given to me in person, orally and reduced to writing,

at least 72 hours prior to the procedure.

Please initial each line.

I have been provided the name of the physician who is to perform or induce the

abortion and a contact number where the physician may later be reached if

questions arise.

I have had the opportunity to ask any questions of the physician concerning the

abortion.

I have been told the probable gestational age of the fetus and have been informed

about the anatomical and physiological characteristics of the fetus.

I have been given a description of the proposed abortion method.

I have been informed of any immediate and long-term medical risks associated with

the proposed abortion method.

I have been informed of any immediate and long-term medical risks associated with

the anesthesia and medication that is to be administered.

I have been informed of any immediate and long-term medical risks associated with

the gestational age of the fetus.

I have been informed of any additional risks associated with any medical conditions I

have and any medical history which I have provided.

I have been given the location of the hospital that offers obstetrical and

gynecological care. This hospital is located within thirty miles of the facility in which

the abortion is being performed, the physician performing or inducing the abortion

has clinical privileges at the hospital, and I may receive follow-up care at the hospital

should complications arise.

I have been given the opportunity to view an active ultrasound. Should I choose to

view an active ultrasound at another provider, I shall have reasonable time to do so

prior to the abortion being performed.

I have been given the opportunity to hear the heartbeat of the developing fetus, if

audible.

_______ I have been notified of alternatives to abortion and have been provided information

concerning these options.

Patient Name_______________________________ Date of Birth_______________

Informed Consent Checklist - Abortion Template