Write your initials before each statement to show that you understand and agree with it.
____ I know that my 3 choices for this pregnancy are parenthood, adoption and abortion.
____ “Medication abortion” means an abortion using drugs. An aspiration abortion uses instruments to empty the uterus or womb. I should not begin a medication abortion unless I am sure that I want to end my pregnancy. I am willing to have an aspiration abortion if the medication abortion fails.
____ I know that medication abortion must occur in the first 9 weeks of pregnancy.
____ I will take 2 medications. The first is mifepristone, which blocks a hormone needed to continue a pregnancy. I will take a 200 mg dose because research shows this dose works. The second drug is misoprostol. It causes the cramps which push out the pregnancy.
____ I will swallow the mifepristone tablet before I leave the health center. I know that this can cause nausea, diarrhea, and cramps.
____ I will take 4 misoprostol tablets home with me. I will take them as instructed.
____ One to six hours after I insert the misoprostol, I will have cramping and bleeding. The cramping can be very strong for a few hours, but usually not for more than 24 hours. The bleeding can be quite heavy with clots for a few hours. I may see some pregnancy tissue (usually white or gray in color). If the heavy bleeding lasts for more than 12 hours, or if I soak more than two maxi pads each hour for two hours in a row, I should call my provider. I should call if I do NOT bleed within 24 hours of inserting the misoprostol.
_____If I start to feel very ill, I will call the health center. Very rarely, women have had “toxic shock” type illness after a medication abortion.
____ I should return for my one-week check-up to make sure that the abortion is complete.
____ The abortion must be complete because misoprostol can cause serious birth defects. If the abortion is not complete, I may need a vacuum aspiration (a suction procedure to empty the uterus) to end the pregnancy.
____ I have read this form and have had time to think about it. I have had all of my questions answered.
____ If a complication occurs, I request and allow the provider to do whatever is necessary to protect my health and welfare.
____ I hereby consent that _____________________________ give me mifepristone and misoprostol for an early medication abortion.
Signature of patient: ___________________________
Date: _____________
Witness: ________________________
Date: _____________
