Abortion Information And Informed Consent Form (Page 2 of 3) in pdf

F-40117 (02/2016) Page 2

Effective Date: February 1, 2016

II. Available Services and Information (Skip items 1-3 below if the fetus has a diagnosis of a lethal anomaly.)

__________________________________________________________________________________________________

(insert name of physician who is to perform, or induce, the abortion, or by a qualified person assisting the physician or other

qualified physician) orally informed me, in person, on _____________________(insert date), at ______________ a.m./p.m.

of the following:

That benefits may be available to me under the Wisconsin Medicaid or BadgerCare Plus Program to pay for

prenatal care, childbirth and neonatal care.

That the man responsible for pregnancy is liable for providing assistance in supporting my child, if born, even if he

has offered to pay for the abortion.

That I have the legal right to terminate my pregnancy or to continue my pregnancy and to keep the child; to place

the child in a foster home for six months; to petition the court to place the child in a foster home or group home or

with a relative; or to place the child for adoption under a process that involves court approval both of the voluntary

termination of parental rights and of the adoption.

That I have the right to receive and review, free of charge, state-printed materials that describe the unborn child

and list agencies that offer alternatives to abortion.

That, if I have received a diagnosis of a disability for the fetus, I have the right to receive and review free of

charge, information on community-based services and financial assistance programs for children with disabilities

and their families, support groups for people with disabilities and parents of children with disabilities, and adoption

of children with special needs.

That I have the right to receive and review, free of charge, information on the availability of public and private

agencies and services that provide birth control information including natural family planning information;

information on services available for victims or individuals at risk of domestic abuse; information about legal

protections for me and my child should I wish to oppose establishment of paternity or to terminate the father’s

parental rights; and information on the availability of perinatal hospice.

The information listed in items 5 and 6 (above) is available through a toll free telephone number,

1-877-855-7296, and in state-printed materials, which are available through this facility.

III. Obstetric Ultrasound Performed at this Facility (If the ultrasound was conducted elsewhere skip this section and go

to section IV.)

(insert name of physician or qualified person who performed the ultrasound)

On _______________________ (insert date), at __________________ a.m./p.m., carried out the following:

Performed an obstetric ultrasound using the transducer I chose, after available options were explained to me.

Provided me an oral explanation during the ultrasound of what it depicted, including the presence and location of

the fetus within the uterus, the number of fetuses, and the occurrence of the death of a fetus, if such a death had

occurred.

Displayed the ultrasound images so that I could view them, but did not require that I do so.

Provided me a medical description of the ultrasound images, including the dimensions of the fetus and a

description of any external features and internal organs present and viewable on the image.

Provided me the means to visualize a fetal heartbeat, but did not require that I do so, if a heartbeat was detectable

by the ultrasound type I chose, and provided me, in a manner understandable to a layperson, a simultaneous oral

explanation.

Abortion Information And Informed Consent Form Page 2