Microsoft word - pillconsentform.doc

POTOMAC FAMILY PLANNING CENTER
Voluntary Informed Consent for Medical Abortion with Mifepristone and Misoprostol I, _____________________, age _____, hereby give my consent to and request and authorize Earl N. McLeod, M.D., or a physician designated by he/she, together with any necessary assistants, to perform upon me, a MEDICAL ABORTION by use of Mifeprex 200mg and Misoprostol 800mcg. I have been informed of other options during early pregnancy including continuing the pregnancy and becoming a parent, continuing the pregnancy and making adoption arrangements, and surgical abortion. I have been informed of the risks involved with a surgical abortion and a medical abortion, and the risks involved with continuing the pregnancy. I acknowledge no guarantee or assurance has been made to me concerning the medical abortion procedure. The nature of pregnancy, the nature and purpose of an abortion, the probability of success
of such a method, the possible physical and psychological effects which might be
unforeseeable, the risks involved, and the possibility of complications including but not
limited to pain and suffering, emotional upset, retained products of conception, bleeding
and infection of varying degrees, ruptured ectopic pregnancy, adverse reaction to
medications, heart attack, and (in rare instances) death, have been fully and reasonably
explained to me. I understand the incidence of fatal toxic shock following medical
abortion is approximately 1 in 125,000. I have fully disclose my medical history
including the date of my last menstrual period, allergies, blood conditions, prior
medications or drugs, and reactions to medications or drugs. I certify that I have read this
form or it has been read to me. I understand its contents and have been given an
opportunity to ask questions. All my questions were answered to my satisfaction. I
further certify that I have been given the Mifeprex Medication Guide, and that I had an
opportunity to read it and discuss it with my provider.
I understand women cope differently with emotional distress associated with abortion and
often go through the process with minimal effect. I understand emotional distress is a
potential complication of abortion and release the clinic, the attending physicians, staff
and assistants from any liability, or responsibility for any conditions including but not
limited to short or long term psychological effects resulting from my decision to have an
elective abortion. I understand that I will be given Mifeprex based on an evidence-based
regimen. Rather than the FDA approved regimen of 600mg Mifeprex and 400mcg of
oral Misoprostol, I will be given a 200mg dose of Mifeprex in the office. I will be
given an 800mcg dose of vaginal Misoprostol to be taken at home. Research shows
that this off label use is a safe and effective alternative regimen and causes less stomach
upset.

I understand that Mifeprex (Mifepristone) and Misoprostol can cause birth defects,
and if the medical abortion is not complete, I agree to have a surgical abortion.
Should hospitalization for any reason be necessary, I understand neither the physician,
employees, clinic nor corporation will be responsible for any costs incurred. I
acknowledge that I have read and understand the FDA approved regimen as outlined in
the Mifeprex Medication Guide and Patient Agreement, I have signed the Patient Agreement, and understand the reason(s) why the FDA approved regimen is being altered. I further acknowledge that I have been given the opportunity to ask questions about the alternative evidence-based regimen and all my questions have been answered to my satisfaction. I understand that this consent form amends the signed Patient Agreement. I certify that I fully understand the above consent to the medial abortion and the nature of the procedure, risks, benefits and alternatives therein referred were fully explained to me and all my questions have been answered to my satisfaction. I have as a result, been able to make an informed intelligent and voluntary choice about undergoing a medical abortion. I certify this consent was made without coercion, duress or haste, while I was of sound mind and under no sedation whatsoever. _______________________________ _______________________________ Patient’s Name Printed _______________________________

Source: http://www.potomacfamilyplanning.com/forms/Pill%20Consent%20Form.pdf