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Informed Consent Confirmation Form

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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, _____________________________, acknowledge that at least 24 hours before the scheduled abortion I have reviewed 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

 


Patient's Signature

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

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.