Parental Consent Form For A Pregnant (Unemancipated) Minor - Arizona Department Of Health Services Page 2
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2ARIZONA DEPARTMENT OF HEALTH SERVICES
PARENTAL CONSENT FORM FOR A PREGNANT (UNEMANCIPATED) MINOR
I, _____________________________________________________________, attest that I am the
(Printed name – parent, legal guardian, or conservator of the pregnant minor)
parent, legal guardian, or conservator of _____________________________________________________.
(Printed name – pregnant minor)
I have been informed of the medical risks associated with any surgical, medical, or diagnostic procedure, a
surgical abortion, and a medication abortion. I hereby give my consent for the pregnant minor named above to
have an abortion performed or induced. I understand that this form is prescribed by the Arizona Department of
Health Services in accordance with A.R.S. § 36-2152.
1. _____________________________________________
____________________
Signature – parent, legal guardian, or conservator of the pregnant minor
Date
I have been informed of the medical risks associated with any surgical, medical, or diagnostic procedure, a
surgical abortion, and a medication abortion. I hereby give my consent to have an abortion performed or induced.
I understand that this form is prescribed by the Arizona Department of Health Services in accordance with A.R.S.
§ 36-2152.
2. _____________________________________________
____________________
Signature – pregnant minor
Date
NOTARIZATION:
State of Arizona
)
)
County of __________________
)
On this __________ day of ______________________, 20____, before me personally appeared
Day
Month
Year
_____________________________________________ and
Printed name – signer #1
_____________________________________________.
Printed name – signer #2
The identity of each person was proven to me on the basis of satisfactory evidence to be the person whom he or
she claims to be, and each person acknowledged that he or she signed the above/attached document.
_____________________________________________
Notary Public
(seal)
2
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