Patient Agreement Mifeprex (Mifepristone) Tablets
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1PATIENT AGREEMENT
Mifeprex (mifepristone) Tablets
1. I have read the attached MEDICATION GUIDE for using Mifeprex and misoprostol to end my pregnancy.
2. I discussed the information with my health care provider (provider).
3. My provider answered all my questions and told me about the risks and benefits of using Mifeprex and
misoprostol to end my pregnancy.
4. I believe I am no more than 49 days (7 weeks) pregnant.
5. I understand that I will take Mifeprex in my provider’s office (Day 1).
6. I understand that I will take misoprostol in my provider’s office two days after I take Mifeprex (Day 3).
7. My provider gave me advice on what to do if I develop heavy bleeding or need emergency care due to the
treatment.
8. Bleeding and cramping do not mean that my pregnancy has ended. Therefore, I must return to my provider’s
office in about 2 weeks (about Day 14) after I take Mifeprex to be sure that my pregnancy has ended and that I
am well.
9. I know that, in some cases, the treatment will not work. This happens in about 5 to 8 women out of 100 who
use this treatment.
10. I understand that if my pregnancy continues after any part of the treatment, there is a chance that there may
be birth defects. If my pregnancy continues after treatment with Mifeprex and misoprostol, I will talk with my
provider about my choices, which may include a surgical procedure to end my pregnancy.
11. I understand that if the medicines I take do not end my pregnancy and I decide to have a surgical procedure
to end my pregnancy, or if I need a surgical procedure to stop bleeding, my provider will do the procedure or refer
me to another provider who will. I have that provider’s name, address and phone number.
12. I have my provider's name, address and phone number and know that I can call if I have any questions or
concerns.
13. I have decided to take Mifeprex and misoprostol to end my pregnancy and will follow my provider’s advice
about when to take each drug and what to do in an emergency.
14. I will do the following:
°
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contact my provider right away if in the days after treatment I have a fever of 100.4
F or higher that lasts
for more than 4 hours or severe abdominal pain.
-
contact my provider right away if I have heavy bleeding (soaking through two thick full-size sanitary pads
per hour for two consecutive hours).
take the MEDICATION GUIDE with me when I visit an emergency room or a provider who did not give me
-
Mifeprex, so that they will understand that I am having a medical abortion with Mifeprex.
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return to my provider’s office in 2 days (Day 3) to check if my pregnancy has ended. My provider will give
me misoprostol if I am still pregnant.
-
return to my provider’s office about 14 days after beginning treatment to be sure that my pregnancy has
ended and that I am well
Patient Signature: ___________________________________________
Patient Name (print): ________________________________________
Date: _____________________________________________________
The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered all her
questions. I have given her the MEDICATION GUIDE for mifepristone.
Provider’s Signature: ________________________________________
Name of Provider (print): ______________________________________
Date: _____________________________________________________
After the patient and the provider sign this PATIENT AGREEMENT, give 1 copy to the patient before she leaves
the office and put 1 copy in her medical record. Give a copy of the MEDICATION GUIDE to the patient.
Rev 1:11/12/04
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