Informed Consent Confirmation Form

Michigan Department of Health and Human Services

In order to comply with MCL 333.17015, you must print this page and present it to the physician or other qualified person assisting the physician.

I, _____________________________, voluntarily and willfully 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))

A. 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 before performance of that procedure.

B. I understand that it is illegal for anyone to coerce me into seeking an abortion

C. I acknowledge that at least 24 hours before the scheduled abortion I have received a physical 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.

D. If any of the documents listed in paragraph C were transmitted by facsimile, I certify that the documents were clear and legible.

E. 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.

F. 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.

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

H. I certify that I have not been required to make any payments for an abortion or any medical service before the expiration of 24 hours after I received the written materials listed in paragraph C, or 24 hours after the time and date listed on the confirmation form if the information described in paragraph C was viewed from the state of Michigan internet website.

I certify that I have reviewed the information on:  {CURRENTDATE|0|1}.

Patient's Signature

By using this form, an abortion cannot be performed before: {CURRENTDATE|1|1}.

This specific form is valid only through: {CURRENTDATE|14|1}.

To verify compliance with the 24-hour notification requirement of MCL 333.17015, this form shall be presented to the physician, or a qualified person assisting the physician, and made part of the patient's medical record.