You must watch the 8 minute video below (at normal speed).

After you watch entire the video, a "next" button will appear below the video and allow you to sign a form certifying that you completed the video.

Pregnancy dating calculator 

My signature below indicates that I watched the Abortion Control Act Infomed Consent video completely at the date and time listed. I understand that I have the option to request to speak to a physician at Allegney Reproductive Health Center (ARHC) regarding any questions. I also understand that I can ask ARHC staff for a copy of the printed materials published by the Pennsylvania Department of Health regarding pregnancy and pregnancy options.

You will complete the following certification on the day of your abortion appointment. 

Click the "submit" button at the bottom of this page to send your form to Allegheny Reproductive Health Center.

I hereby certify that the physician who I understand will perform my abortion or refer me to another physician who will perform the abortion, has orally informed me of the following:

1. What an abortion is and how it will be performed, as well as the potential risks of both abortion and carrying the pregnancy to term (delivering).
2. Alternatives to abortion, including carrying the pregnancy to term, setting up an adoption plan, or foster care.
3. The probable gestational age of my pregnancy.
4. Materials published by the Pennsylvania Department of Health, which offer information regarding abortion alternatives and fetal development, and that these materials are available to me at no cost if I request them.
5. Medical Assistance benefits may be available for prenatal, childbirth, and neonatal care, and that more information regarding these benefits is in the state-printed materials.
6. The person with whom I became pregnant is liable for child support, even if they have offered to pay for the abortion.

By signing, I certify that all of my questions have been answered to my satisfaction, and that I have heard and understood the information required by the Pennsylvania Abortion Control Act at least 24 hours before my scheduled abortion. I also certify I was given the opportunity to request to see the state-printed materials, and if I requested these, that they were provided to me.

Signature: _______________________   Date: ___________ Time: ___________