Abortion Information And Informed Consent Form printable pdf download

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

Wisconsin Statute Chapter 253

F-40117 (Rev. 02/2016)

Effective Date: February 1, 2016

ABORTION INFORMATION PROVISION CERTIFICATION

General Information and Instructions:

Wisconsin Statute 253.10(3) requires that a physician explain certain things to you at least 24 hours before you receive an

abortion except in the case of a medical emergency or if the pregnancy is the result of a sexual assault or incest. The

physician must supply you with all the information below, unless he/she determines a particular item of information would

cause a significant, non-temporary threat of severe harm to your mental health. The law also requires that you voluntarily

agree to an abortion in writing and that you complete this form.

For each statement below, check the box by the statement if you agree that the information was provided to you.

The physician who is to perform or induce the abortion is:

______________________________________________________________________________________________________

(To be filled in by the physician who is to perform, or induce, the abortion, or by a qualified person assisting the physician.)

I. Informed Consent

_______________________________________________________________________________ (insert name of physician)

orally informed me, in person, on _________________ (insert date), at _______________ a.m./p.m., of the following:

According to my physician’s reasonable medical judgment, I am pregnant and the probable gestational age of the

fetus, on this date, is _____________________ weeks. The numerical odds of survival for an unborn child delivered

at that probable gestational age are ________________. This information was also provided to me in writing.

The probable anatomical and physiological characteristic of the fetus on this date.

The particular medical risks, if any, associated with my pregnancy.

The details of the medical or surgical method that would be used in performing or inducing an abortion.

The medical risks associated with the particular abortion procedure that would be used, including the risk of

infection, psychological trauma, hemorrhage, endometritis, perforated uterus, incomplete abortion, failed abortion, or

danger to subsequent pregnancies and infertility.

The recommended general medical instructions to follow an abortion to enhance safe recovery and the name and

telephone number of a physician to call if complications arise.

Physician’s telephone number: ________________________________________ (To be filled in by the provider.)

If, in the reasonable medical judgment of my physician, the fetus has reached viability, that the physician who is to

perform or induce the abortion is required to take all steps necessary under law to preserve the life and health of the

fetus.

That I have the right to withdraw consent, cancel the appointment, or not show for the appointment at any time

before the procedure is performed.

That no payment for the procedure may be required from me until at least 24 hours have elapsed after the informed

consent consultation has been completed, except if the waiting period is shortened by me because the pregnancy is

the result of sexual assault or incest or medical emergency.

10. A list of providers that would perform the required ultrasound at no cost to me.

Abortion Information And Informed Consent Form