Informed Consent Checklist - Abortion Template (Page 2 of 2) in pdf

Informed Consent Checklist - Abortion Template Page 2

I certify that the following information has been given to me:

• The booklet titled “Missouri’s Informed Consent Booklet” which provides

information on: how your baby grows during pregnancy, methods of induced

abortion and its risks, fetal pain, paternity information for moms and dads,

information about child support, and information concerning “alternatives to

abortions.” Including the Alternatives to Abortion program.

• A List of Alternatives to Abortion Program Providers.

• A List of Pregnancy Assistance Information Providers.

• A List of Fetal Ultrasound Providers.

I understand that I am free to withhold or withdraw my consent for an abortion at any

time without affecting my rights to future care or treatment and without the loss of

any state or federally funded benefits to which I might otherwise be entitled. I certify

that this information was provided in an individual setting that protected my privacy

and maintained the confidentiality of my decision. I certify that my decision is

voluntary and informed, free and without coercion.

I attest that I have been given all of the above information by a qualified professional on

Date____________________

Time_______________

Patient Signature: _________________________________________ Date_____________

Parent/Guardian Signature: _________________________________ Date_____________

Qualified Professional: _____________________________________ Date_____________

Patient Name_______________________________ Date of Birth_______________

Informed Consent Checklist - Abortion Template Page 2