____ I request a Manual Vacuum Aspiration (MVA), a procedure that will empty my uterus. This procedure may be used as an aspiration abortion or as treatment for a miscarriage or a failed medication abortion.
____ I understand that if I am pregnant, my three options regarding this pregnancy are parenthood, adoption, and abortion. I understand that if I am pregnant, the MVA will end my pregnancy.
____ I understand that before the MVA, I may have blood tests done to check me for anemia and I will have to document my Rh type by donor card, prior blood test or a new blood test. If I am Rh negative, I will get a shot of MicRhogam.
____ I understand that I might be offered 2 medications before the MVA: Ibuprofen to lessen the cramping and misoprostol to help open my cervix. I will have local anesthesia with lidocaine injected. To the best of my knowledge, I am not allergic to Ibuprofen, misoprostol, or lidocaine.
____ I understand that the possible complications from MVA include: incomplete emptying of my uterus, infection, bleeding, allergic reaction and perforation.
____ I have read this form and have had time to think about it. I have had all of my questions answered.
____ I have been given an information sheet explaining how and when to get help should a question or problem arise after the procedure.
____ In the event of an unexpected complication during the MVA, I request and authorize the physician to do whatever is needed to protect my health and welfare.
____ I hereby consent that _____________________________ do the procedure “manual vacuum aspiration” for me.
Signature of patient: _____________________________ Date: ____________
Witness: _______________________________________ Date: ____________
