I, _______________________________________ , hereby authorize Dr. ___________________________________ ("the physician") and any assistant designated by the physician to perform upon me the following operation(s) or procedure(s):

I understand that I am approximately _____ weeks pregnant. I consent to an abortion procedure to terminate my pregnancy. I understand that I have the right to withdraw my consent to the abortion procedure at any time prior to performance of that procedure. I acknowledge that at least 24 hours before the scheduled abortion I have received a physical copy of each of the following:

• A medically accurate depiction, illustration, or photograph of a fetus at the probable gestational age of the fetus I am carrying.
• A written description of the medical procedure that will be used to perform the abortion.
• A prenatal care and parenting information pamphlet.

If any of the above listed documents were transmitted by facsimile, I certify that the documents were clear and legible.

I acknowledge that the physician who will perform the abortion has orally described all of the following to me:

• The specific risk to me, if any, of the complications that have been associated with the procedure I am scheduled to undergo.
• The specific risk to me, if any, of the complications if I choose to continue the pregnancy.

I acknowledge that I have received all of the following information:

• Information about what to do and whom to contact in the event that complications arise from the abortion.
• Information pertaining to available pregnancy related services.

I have been given an opportunity to ask questions about the operation(s) or procedure(s).

I understand that I may sign this form if I have made payments to the physician or an agent of the physician, in whole or in part, for medical services provided to or planned for me, as long as I did not make such payments within 24 hours after I scheduled an abortion to be performed by the physician and/or I did not make such payments within 24 hours after the physician or a qualified person assisting the physician personally gave me a copy of the written materials listed in paragraphs (1.), (2.), and (3.) in the consent form above.