Date: _____________
Patient Name: _______________________________________________
I understand that I am being tested to determine whether I am Rh Positive or Rh negative (my blood type).
If I am Rh negative, I will need to return to the office within three days to get an injection of micrhogam. I understand that if I am Rh negative and do not return to the office, I could jeopardize future pregnancies. It is my responsibility to call [YOUR HEALTH CENTER NAME HERE] within the next three days to get these results.
If I am Rh negative, [YOUR HEALTH CENTER NAME HERE] will also notify me at the following number, where they can leave a message:
___________________ Alternate phone number: ___________________
(Signature): ______________________________ Date: _______________
