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:
- 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).
- Alternatives to abortion, including carrying the pregnancy to term, setting up an adoption plan, or foster care.
- The probable gestational age of my pregnancy.
- 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.
- 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.
- 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: _________________________