PATIENT AGREEMENT FOR MEDICAL ABORTION

PATIENT AGREEMENT FOR MEDICAL ABORTION

1. Doctor answered all my questions and told me about the risks and benefits of using medical abortion pills / tablets to end my pregnancy.

2. I believe I am no more than 49 days (7 weeks) pregnant.

3. I understand that I will take one tablet in Doctor’s clinic (Day 1).

4. I understand that I will attend his clinic for second dose two days after I take first dose (Day 3).

5. Doctor gave me advice on what to do if I develop heavy bleeding or need emergency care due to the treatment.

6. Bleeding and cramping do not mean that my pregnancy has ended. Therefore, I must return to Doctor’s clinic in about 2 weeks (about Day 14) after I take tablets to be sure that my pregnancy has ended and that I am well.

7. I know that, in some cases, the treatment will not work. This happens in about 5 to 8 women out of 100 who use this treatment.

8. I understand that if my pregnancy continues after any part of the treatment, there is a chance that there may be birth defects. If my pregnancy continues after treatment with Medical abortion pills / tablets , I will talk with Doctor about my choices, which may include a surgical procedure to end my pregnancy.

9. I understand that if the medicines I take do not end my pregnancy and I decide to have a surgical procedure to end my pregnancy, or if I need a surgical procedure to stop bleeding, Doctor will do the procedure or refer me to another Doctor l. I have that provider’s name, address and phone number.

10. I have Doctor's name, address and phone number and know that I can call if I have any

questions or concerns.

11. I have decided to take Medical abortion pills / tablets to end my pregnancy and will follow my provider’s advice about when to take each drug and what to do in an emergency.

12. I will do the following:

- contact Doctor right away if in the days after treatment I have a fever of 100.4°F or higher

that lasts for more than 4 hours or severe abdominal pain.

- contact Doctor right away if I have heavy bleeding (soaking through two thick full-size

sanitary pads per hour for two consecutive hours).

- contact Doctor right away if I have abdominal pain or discomfort, or I am “feeling sick”,

including weakness, nausea, vomiting or diarrhea, more than 24 hours after taking abortion pills.

- return to Doctors clinic about 14 days after beginning treatment to be sure that my

pregnancy has ended and that I am well.

Patient Signature: ____________________________________

Patient Name:______________________________________Date:_________________

The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered all her questions.

Doctor’s Signature: ________________________________________

Name of Doctor : ______________________________________Date: _________________

One copy to the patient before she leaves the clinic and put one copy in file of her medical record.