Paent Name: __________________________________________ Date of Birth: ________________
NCDHHS MEDICAL ABORTION CONSENT FORM
AND ACKNOWLEDGEMENT OF RISKS STATEMENT
By inialing each of the items below, I cerfy that I have received the following informaon about my care:
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The physician that will provide the abortion-inducing medication(s) is ____________________.
NAME OF PHYSICIAN
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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 malpracce in the performance of an aboron unless otherwise
communicated.
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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.
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Check if not applicable.
The provider does or does not accept my insurance.
(Oponal) If no hospital is located within 30 miles, the following may be the closest hospital:
_________________________________________________________________________.
S/he does or does not have adming 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.
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I understand that the probable gestational age of my pregnancy at this time is _____weeks.
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I understand that medicaon(s) will be used that will end my pregnancy and cause the
uterus to contract to expel the pregnancy ssue. Aer receiving these medicines, I might
experience cramping, pelvic pain or bleeding, and the passing of clots and ssue within
hours or days. Medicaons may be given for the pain, cramping and nausea.
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I understand the specific medical risks and potenal complications of medical abortion.
I understand that the risks of complicaons of medical aborons increase with advancing
gestaonal age. (See Below)
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I understand the specific medical risks and potential complications of carrying the
pregnancy to term (See Below).
Risks*
Medical Abortion
Term Pregnancy Delivery
Infection
Less than 1 in 100
4 in 100
Hemorrhage (Excess Bleeding)
Less than 1 in 100
4-5 in 100
Incomplete abortion/Retained
pregnancy tissue
5 in 100
3 out of 100 (retained placenta)
Connuaon of the pregnancy
Less than 1 in 100
Does not apply
Risks to future pregnancies:
Inferlity
Not increased when there are
no complicaons
Not increased when there are
no complicaons
Death (both medical or surgical
aboron)**
Less than 0.5 in 100,000
aborons
17-27 per 100,000 live births
*Esmates based on exisng studies. For example, 5 in 100 means that 5 people out of 100 who had medical
aboron could experience the specic risk.
**For abortions after 13 weeks, infecon and hemorrhage (bleeding) were the leading causes of death.
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I understand that blood type differences (Rh incompatibility) between the pregnant person
and the fetus sometimes occur and could cause risks to future pregnancies. Medication is
available to prevent this (Rh Immunoglobulin) and some individuals can receive an injection
of Rh immunoglobin at the time of the medical abortion to prevent potential future
incompatibilities.
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I understand that I may see the remains of my pregnancy during the process of completing
the medical abortion outside the clinic.
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I may view the fetus(es) by real-time ultrasound and listen to fetal heart tones if present
prior to the procedure. I understand that printed information is available to me about
locations to receive a pregnancy ultrasound free of charge.
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I have been given an opportunity to ask questions about my pregnancy, how the embryo
and fetus develop, and alternaves to medical abortion.
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I understand options other than abortion include carrying the pregnancy to term and either
keeping the infant(s) myself or placing the infant(s) for adoption.
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I understand a medical abortion is intended to end my pregnancy.
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I understand health insurance benefits may be available to me for prenatal care, childbirth,
and newborn care.
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I understand public assistance benefits may or may not be available to me under Federal
and State assistance programs.
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I understand if I choose to carry the pregnancy to term, the father of this pregnancy may
be legally obligated to assist in support of the child(ren), even if the father has offered to
pay for the abortion.
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I was told about materials developed by the North Carolina Department of Health and
Human Services which describe fetal development and list agencies that offer alternatives
to abortion which are available at www.ncdhhs.gov/reprohealth. If I requested printed
versions of these materials to review rather than the website, these materials were
provided at least 72 hours before the medical abortion.
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I was told that the decision to undergo a medical abortion is completely up to me. I was told
that I could withdraw my consent for abortion at any time including after the first medication
but before the second medication is administered. No matter what I decide, my decision will
not affect my right to future care or treatment. I will not lose any help or benefits from
programs receiving State or Federal funds, for which I may otherwise be eligible.
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I understand that I have a private right of acon to sue the qualied physician performing
the aboron if I feel I have been coerced or misled prior to having an abortion. State
resources about this right are located at: www.nccourts.gov/help-topics/lawsuits-and-
small-claims/lawsuits
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I understand that I will be given a copy of all signed forms required by law for this procedure.
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I understand that my physician will schedule an appointment 7-14 days after providing the
abortion-inducing drug(s) to confirm that the pregnancy is completely terminated and to
check for any complicaons.
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I have been given enough information to give informed consent to a medical abortion.
I understand that I will undergo a medical abortion. The discomforts, risks, benefits, and alternatives
of the procedure have been explained to me. All my questions have been answered to my satisfaction.
I also understand that my anonymous medical data will be released to representatives from the North
Carolina Department of Health and Human Services as required by State law, and I understand that I
can object in wring to having my medical records reviewed. My foregoing inials and signature and
my signature below, conrm that I have voluntarily acknowledged and consented to each specic item
listed above.
_____________________________________________ ________________________________
SIGNATURE OF PATIENT/PERSON AUTHORIZED TO CONSENT DATE AND TIME
_____________________________________________ ________________________________
PRINTED NAME OF PATIENT/PERSON AUTHORIZED TO CONSENT RELATIONSHIP TO PATIENT (IF APPLICABLE)
I aest that I have provided this paent with the informaon presented above in-person.
_____________________________________________
SIGNATURE OF THE QUALIFIED PROFESSIONAL PROVIDING COUNSELING
_____________________________________________ ________________________________
PRINTED NAME DATE AND TIME
Complete if physician is dierent than previously noted:
I have informed the paent that the physician who will see them is Dr. _________________________.
S/he does have local hospital adming privileges at _______________________________________.
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STAFF INITIALS