Parental Consent Form For A Pregnant (Unemancipated) Minor - Arizona Department Of Health Services
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2ARIZONA DEPARTMENT OF HEALTH SERVICES
PARENTAL CONSENT FORM FOR A PREGNANT (UNEMANCIPATED)
MINOR
PLEASE BE ADVISED THAT IN ACCORDANCE WITH ARIZONA REVISED STATUTES (A.R.S.) § 36-2152(M), THE
PHYSICIAN MUST MAINTAIN THIS PARENTAL CONSENT FORM IN THE PREGNANT MINOR’S RECORDS FOR SEVEN
YEARS AFTER THE DATE OF THE PROCEDURE OR FIVE YEARS AFTER THE DATE OF THE MINOR’S MATURITY,
WHICHEVER IS LONGER.
The parent, legal guardian, or conservator of the pregnant minor and the pregnant minor are hereby informed as
follows:
1.
The possible medical risks that may occur with any surgical, medical, or diagnostic procedure
include:
•
Infection
•
Blood clots
•
Hemorrhage
•
Allergic reactions
•
Death
2.
The possible medical risks that may occur with a surgical abortion include:
•
Hemorrhage
•
Uterine perforation
•
Sterility
•
Injury to the bowel or bladder
•
Hysterectomy as a result of a complication or injury during the
surgical abortion
•
Additional procedure resulting from the failure to remove all
products of conception
3.
The possible medical risks that may occur with a medication abortion include:
•
Hemorrhage
•
Infection
•
Additional procedure resulting from the failure to remove all
products of conception
•
Sterility
•
Continuation of the pregnancy
______ Initials – parent, legal guardian, or conservator of the pregnant minor
______ Initials – pregnant minor
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