Request For Emergency Contraception Pills Page 3
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3If you have any questions about emergency birth control pills, ask your healthcare provider.
I have read and understand the information above.
Patient Signature: ___________________________________ Date: _______________________
The client has been counseled, provided with the appropriate informational material, and
understands the content of both.
Counselor/Provider signature: __________________________ Date: ______________________
Print counselor/provider name: _____________________________________________________
Name of patient: _______________________ Date of Birth: _________ Chart #:____________
Interpreter: _______________________________________________________________________
REQUEST FOR EMERGENCY CONTRACEPTION PILLS
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