Paent Name: __________________________________________ Date of Birth: ________________
NCDHHS MEDICAL ABORTION CONSENT FORM
AND ACKNOWLEDGEMENT OF RISKS STATEMENT
By inialing each of the items below, I cerfy that I have received the following informaon about my care:
The physician that will provide the abortion-inducing medication(s) is ____________________.
NAME OF PHYSICIAN
If the specific physician is not known, or changes after the time of this consent, the name
will be noted below. S/he will be physically present while the first abortion-inducing drug
is administered.
S/he does or does not have local hospital admitting privileges at
_____________________________________________, which offers obstetrical or
HOSPITAL NAME
gynecological care and is located at _____________________________________________
HOSPITAL ADDRESS
which is within 30 miles from the facility where the abortion is being performed. S/he has
liability insurance to cover malpracce in the performance of an aboron unless otherwise
communicated.
Check if not applicable.
If applicable, I have been given the name and contact information of the physician or physician
team that will take care of me in the case of any complications after the procedure.
Check if not applicable.
The provider does or does not accept my insurance.
(Oponal) If no hospital is located within 30 miles, the following may be the closest hospital:
_________________________________________________________________________.
S/he does or does not have adming privileges.
By signing here _________________________________ and initialing each of the items below, I certify
that I have been orally informed, in-person, by a qualified health professional, of the following specific
information, at least 72 hours before the first abortion-inducing medication was given.
I understand that the probable gestational age of my pregnancy at this time is _____weeks.
I understand that medicaon(s) will be used that will end my pregnancy and cause the
uterus to contract to expel the pregnancy ssue. Aer receiving these medicines, I might
experience cramping, pelvic pain or bleeding, and the passing of clots and ssue within
hours or days. Medicaons may be given for the pain, cramping and nausea.