Acknowledgement and Consent Form

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

(Name of 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 understand that it is illegal for anyone to coerce me into seeking an abortion. I acknowledge that at least 24 hours before the scheduled abortion I have received or viewed a copy of each of the following:

1. A medically accurate depiction, illustration, or photograph of a fetus at the probable gestational age of the fetus I am carrying
2. A written description of the medical procedure that will be used to perform the abortion
3. A prenatal care and parenting information pamphlet
4. A prescreening summary on prevention of coercion to abort.

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:

1. The specific risk to me, if any, of the complications that have been associated with the procedure I am scheduled to undergo.
2. 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:

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

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

I certify that I have not been required to make any payments for an abortion of any medical services before the expiration of 24 hours after I received the written materials a), b), c) or d) listed above, or 24 hours after the time and date listed on the confirmation form under paragraph C.

Patient Signature                                                                                                  Date