PREGNANCY CONFIRMATION INTAKE

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Last 4 of Social Security Number * This field is required.*
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Full Name* This field is required.
First Name
Last Name
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Birth Date* This field is required.
Month
Day
Year
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What is your age?* This field is required.
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First day of last menstrual period* This field is required.
Enter the day to started your period for the last time
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Thank you for scheduling with Choices Women's Center. The following information is to help you prepare for your appointment.
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Ultrasound Appointment Notice

The cost of an ultrasound visit is $125, preferably paid in cash to avoid an additional service charge.

You have scheduled an appointment for an ultrasound only.

If at any time you decide you need additional services, a separate appointment will be required.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Contact Number* This field is required.
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Email Address* This field is required.
example@example.com
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Emergency Contact Name* This field is required.
First Name
Last Name
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Relationship to Emergency Contact* This field is required.
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Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
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We will be collecting a urine sample
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Valid government picture ID is required for you, including MINORS and anyone who enters our office
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No children allowed in the office
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No one is allowed in the exam room with you
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No cell phones are permitted in the exam rooms
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Please select one* This field is required.
I need an ultrasound to terminate my pregnancy here at Choices Women's Center
I need an ultrasound and plan on continuing my pregnancy
I need an ultrasound to terminate my pregnancy with a provider in Phoenix or other location
I need an ultrasound to terminate my pregnancy with medication I purchased elsewhere and or plan on purchasing elsewhere
I bought the Abortion Pill Online and need an ultrasound before I take the medication
I bought the Abortion Pill Online and need an ultrasound to make sure I am no longer p
Other
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Will you need a translator?* This field is required.
YESNO
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In what language will you need translation?* This field is required.
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Have you had a positive pregnancy test?* This field is required.
YESNO
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No show Cancellation Policy:* This field is required.I understand and agree with Choices Women's Center no show and cancellation policy. 6 hours in advance if you will not be able to keep your appointment. Failure to cancel in advance will result in a cancellation fee will be charged to the credit card on file: $25. If you no show your appointment, a no-show fee of will be charged to the credit card on file: $25
Initials
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Notifications* This field is required.I understand that if I need to cancel or reschedule my appointment. I must use the Square link that was sent to me via text or email, by visiting Square.com or following this link https://squareup.com/appointments/book/hkugu66buyranm/LJQ99VCGNKBY8/start. Do not call the office to cancel or reschedule your appointment, as the office staff is unable to cancel or reschedule your appointment. If you require further assistance please email frontdesk@tucsonchoices.com.
Intials
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I understand Choices Women's Center does NOT complete or fill out any FMLA, Disability, or Employer paperwork.* This field is required.
Initials
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I understand that if I do pay with a credit card that the person must be present with a picture ID with the same name on the credit card. No Exceptions.* This field is required.
Initials
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I understand that I will be receiving a vaginal ultrasound to determine how far along I am in the pregnancy. This ultrasound is for dating purposes only. It will not assess for abnormalities or determine the sex of the fetus.* This field is required.
Initials
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Are you allergic to latex* This field is required.
Yes
No
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Is there anything we haven't asked that you think is important for us to know, please write it here.* This field is required.
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Signature* This field is required.
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Date* This field is required.
Date
Month
Day
Year
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REQUEST FOR ULTRASOUND EXAMINATION

I understand that an ultrasound is a procedure that enables the clinician to view my pregnancy to determine the age of the fetus and look at other structures in my uterus. This is done with an instrument that sends sound waves through the amniotic fluid (water bag).

I understand that this ultrasound is being done only to determine the age of the fetus and no abnormalities of my pregnancy, fetus, or reproductive tract. More extensive studies may be needed to diagnose specific conditions or abnormalities in the pregnancy. If more extensive studies are required, I understand that I will be referred to a specialist for further testing. I also understand there are limitations to all imaging techniques, and that no technique is 100% accurate or reliable.

While there is no evidence at present to prove the negative effects of ultrasound on a developing fetus, I am aware there may be an unrecognized risk with long-term exposure in any procedure.

I have read the above information and have had all my questions answered.

I release Choices Women’s Center and its staff and employees from any liability arising out of or connected with this procedure, particularly regarding any abnormalities of my pregnancy, fetus, or reproductive tract which have not been evaluated by this study.

I hereby request that a staff person authorized by Choices Women’s Center perform an ultrasound screening on me for the sole purpose of determining the age of the fetus.

I hereby give my permission to Choices Women’s Center employees and others authorized by them to use information in my medical record for statistical purposes, with the understanding that confidentiality will be maintained.
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Signature* This field is required.
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Request for Medical Services

Before you give your consent, be sure you understand the information we have provided you. If you have any questions as you read, we will be happy to discuss them with you. Remember that your sent is entirely voluntary. You may ask for a copy of this consent form.

Place your initials after each statement to indicate that you have read, understand, and agree with the statement.
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The nature of the test(s), procedure(s), or treatment(s) to be provided have explained to me. I understand that a clinician/physician is available to answer my questions I may have. * This field is required.
Initials
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I realize that if the tests are taken for certain sexually transmitted infections, the law requires reporting of positive results to the public health agencies.* This field is required.
Initials
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I will be given referrals for further diagnosis or treatment if necessary. I understand that if a referral is needed, I will assume responsibility for obtaining and paying for this care. I have been told how to get care in case of a medical emergency.* This field is required.
Initials
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I hereby request that a person authorized by Choices Women’s Center provide the appropriate evaluation, testing, and treatment.* This field is required.
Initials
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I hereby give permission to Choices Women’s Center employees and other authorized by them to use the information in my medical record for statistical purpose, with the understanding that my confidentiality will be maintained.* This field is required.
Initials
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Signature* This field is required.
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HIPAA Acknowledgement

By signing, I acknowledge that I received a copy of my healthcare provider’s Notice of Privacy Practices (NPP).
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Signature* This field is required.
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