Only the patient may complete this paperwork.
If you are the person having the abortion, please continue.

Thank you for scheduling with Choices Women's Center. The following information is to help you prepare for your appointment.

Abortion care is completed in one visit. The total cost is $860 when paying with cash, or $889.33 when paying by credit card (includes processing fee).

 We will be collecting a urine sample

Valid government picture ID is required for you, including MINORS and anyone who enters our office

No children allowed in the office

No one is allowed in the exam room with you

No cell phones are permitted in the exam rooms

Information for patients on Rh testing and Rh immune globulin (RhoGAM® or WinRho®) for abortion

The National Abortion Federation no longer recommends Rh testing and Rh immune globulin for patients having an abortion below eleven weeks.

Why do people need Rhogam during pregnancy?
Patients who are Rh-negative need Rh immune globulin (RhoGAM® or WinRho®) at 28 weeks pregnant and at delivery to prevent problems in a future pregnancy. About 15% of women are Rh-negative, depending on their race and ethnicity. If an Rh-negative woman is carrying an Rh- positive fetus, some of the fetal blood cells can get into the pregnant person’s circulation and cause the them to be sensitized to any future Rh-positive pregnancy. If they become pregnant again, their own immune system can attack the future pregnancy, causing harm for the fetus. Rh immune globulin prevents the Rh-negative person from getting sensitized, protecting any future pregnancy from problems.

I’ve always had a Rhogam shot during my pregnancies, why am I not getting one now?
There is no data that supports people who are Rh negative, and early in their pregnancy, need RhoGAM® to prevent problems in future pregnancies. New evidence shows that the Rh immune globulin is not needed for an early abortion because of the volume of fetal blood cells in maternal circulation at this time in pregnancy is too low to cause sensitization. Because Rh immune globulin is a human blood product, it has potential risk and real cost for the patient without demonstrated benefit and is no longer recommended by the National Abortion Federation.

Do I need a RhoGAM® shot for a later abortion?
Because the potential for fetal blood cells in maternal circulation grows as the pregnancy advances, patients who are having an abortion later in pregnancy still need their blood type tested and, if they are Rh-negative, need Rh immune globulin.

I’m not planning on getting pregnant again. Do I need a RhoGAM® shot?
Because Rh immune globulin prevents problems in future pregnancy, if you are sure that you don’t want to be pregnant in the future, you do not need to have Rh immune globulin.

I understand but still want to get a RhoGAM® shot.
If you wish to get a RhoGAM® shot, you can get one here or from another health care providers within 72 hours of the abortion procedure.

REQUEST FOR ULTRASOUND EXAMINA­TION

Purpose: You will have an ultrasound before your abortion. This ultrasound is only done to see how far along the pregnancy is and to make sure that the pregnancy is in the uterus.

This ultrasound will not tell us if there are problems with the pregnancy or with your uterus or ovaries. It also will not show the sex of the pregnancy.

Procedure: The ultrasound may be done with a wand on your belly or inside your vagina. This depends on how early the pregnancy is.

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.

I have read this information. I know I can ask questions at any time. This is my choice, and I do not hold my provider or clinic staff responsible for it.

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.

HIPAA Acknowledgement 

By signing, I acknowledge that I received a copy of my healthcare provider’s Notice of Privacy Practices (NPP).

Follow-up care:
We no longer automatically schedule follow-up appointments. If you would like an in-office visit, you may schedule one online 3 weeks after taking the abortion pill.

You may also purchase a low-sensitivity pregnancy test for $25, and reach out anytime with questions or concerns.

Medication Abortion Consent Form: Mifepristone & Misoprostol

What is a medication abortion?
A medication abortion uses two medicines to end a pregnancy:
• Mifepristone is the first medicine. It blocks a hormone called progesterone, which the pregnancyneeds to grow.
• Misoprostol is the second medicine. It opens the cervix (the opening to the uterus) and causes cramping and bleeding to empty the uterus.

What are the benefits of a medication abortion?
It is a safe and effective way to end a pregnancy. You can take it at home in private. You do not need a pelvic exam or a medical procedure in a clinic.

How well does a medication abortion work?
It works more than 95 out of 100 times. About 5 out of 100 people may need extra care to finish the abortion or to treat side effects.

Purpose: I understand that the purpose of abortion is to end a pregnancy.

Consent: I have chosen to have a medication abortion. No one is forcing me or pressuring me to make this decision – this is my choice.

Ultrasound: I will have an ultrasound to see how far along the pregnancy is. It will not show the sex of the pregnancy or if it is healthy. I can choose whether I want to know the number of pregnancies (ex. twins or triplets).

Laboratory: I agree to have any lab work that is needed before my abortion.
Risks: Medication abortion is very safe. But, like any kind of medical care, there are some risks. I also understand that ending a pregnancy – by abortion, miscarriage, or birth – can have risks to my health.

• Pregnancy continues: Sometimes the pregnancy does not end after taking the medicine. If that happens, more medicine or a procedure may be needed to finish the abortion. This is important because misoprostol can cause birth defects.

• Incomplete abortion: Some pregnancy tissue may stay inside the uterus. This can cause bleeding, infection, or cramping that does not stop. More medicine or a procedure may be needed.

• Heavy bleeding: Some people bleed more than expected. A provider may give more medicine or do a procedure, if needed. Very rarely, a blood transfusion or surgery to remove the uterus (hysterectomy) may be needed.

• Infection: Less than 1 in 100 people get an infection after a medication abortion. Infections are treated with antibiotics. Rarely, a suction procedure may be needed.

• Allergic reaction: Some people may be allergic to one of the medicines. This is rare.

• Ectopic pregnancy: Medication abortion will not work on a pregnancy outside of the uterus (ectopic pregnancy). This may require surgery in a hospital instead.

• Emotional reaction: It is normal to feel a mix of emotions after an abortion. Most people do not have long-term emotional problems. Call us if you feel severely sad for more than 2 weeks.

• Death: Death from medication abortion is extremely rare.

• The risk of dying from childbirth is about 10 to 20 times higher than dying from          an abortion.

• The risk of dying from staying pregnant is more than 30 times higher than dying        from an abortion.

Side Effects: Most side effects happen when the pregnancy is passing. They go away soon after.

• Cramping: This is a normal part of the abortion process. It is usually the                  strongest when the pregnancy is passing. Cramping may last a few days.

You can take over-the-counter pain medicine, like ibuprofen (Advil, Motrin) or acetaminophen (Tylenol).

• Bleeding: This is also a normal part of the abortion process. Bleeding is usually heaviest when the pregnancy is passing.

o Call us if you soak 2 pads an hour for 2 hours in a row.

o Call us if you have no bleeding or cramping after taking misoprostol.

o Light bleeding or spotting for 4 to 6 weeks after the abortion is normal.

• Fever/chills: Misoprostol can cause fever or chills. This usually goes away on its own.

o Do not take your temperature in the first 24 hours.

o Call us if your temperature is over 100.4°F more than 24 hours after taking misoprostol.

• Other side effects: You may have nausea, vomiting, diarrhea, headache, dizziness, back pain, and tiredness. These are side effects of misoprostol, the abortion process, and pregnancy itself. They should go away within 24 hours.

o Call us if you still have belly pain more than 24 hours after taking misoprostol.

Follow-up: It is important to check that the abortion worked and that I am feeling well. 

Emergency Contact Information:
I agree to call the 24-hour emergency phone line at any time if I have any questions or problems. (520-210-8300)

I have read this information. I know I can ask questions at any time. I take full responsibility for my choice and understand the risks and consequences involved. I do not hold my provider or clinic staff responsible for what may happen because of my decision.

PATIENT AGREEMENT FORM 

(you will also sign a hard copy of this form in the office on the day of your appt)

Healthcare Providers: Counsel the patient on the risks of mifepristone. Both you and the patient must sign this form. 

Patient Agreement:
1.  I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my provider’s advice about when to take each drug and what to do in an emergency.

2.  I understand:

a.  I will take mifepristone on Day 1.

b.  My provider will either give me or prescribe for me the misoprostol tablets, which I will take 24 to 48 hours after I take mifepristone.

3.  My healthcare provider has talked with me about the risks, including:

•  heavy bleeding

•  infection

•  ectopic pregnancy (a pregnancy outside the womb)

4.  I will contact the clinic/office right away if in the days after treatment I have:

•  a fever of 100.4°F or higher that lasts for more than four hours

•  severe stomach area (abdominal) pain

•  heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)

•  stomach pain or discomfort, or I am “feeling sick,” including weakness, nausea, vomiting, or diarrhea, more than 24 hours after taking misoprostol

5.  My healthcare provider has told me that these symptoms could require emergency care. If I cannot reach the clinic or office right away my healthcare provider has told me who to call and what to do.

6.  I should follow up with my healthcare provider about 7 to 14 days after I take mifepristone to be sure that my pregnancy has ended and that I am well.

7.  I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use this treatment. If my pregnancy continues after treatment with mifepristone and misoprostol, I will talk with my provider about a surgical procedure to end my pregnancy.

8.  If I need a surgical procedure because the medicines did not end my pregnancy or to stop heavy bleeding, my healthcare provider has told me whether they will do the procedure or refer me to another healthcare provider who will.

9.  I have the MEDICATION GUIDE for mifepristone. I will take it with me if I visit an emergency room or a healthcare provider who did not give me mifepristone so that they will understand that I am having a medical abortion with mifepristone.

10.  My healthcare provider has answered all my questions.

Patient Rights and Responsibilities

Patient Rights

1.        Patients have the right to a reasonable response to their requests and needs for treatment or services within the healthcare provider’s capacity, stated mission, and applicable laws and regulations.

2.        Patients have the right to considerate and respectful care that recognizes their personal values and belief systems.

3.        Patients, in collaboration with their physician, have the right to make decisions about their healthcare, including the right to accept, refuse, or withdraw consent for treatment as permitted by law. They have the right to be informed of the medical consequences of such refusal.

4.        Patients have the right to receive the information necessary to make treatment decisions that align with their wishes. This includes being informed about proposed medical or surgical procedures, associated risks, potential complications, and alternatives.

5.        Patients have the right to access counseling services provided directly by their healthcare provider or through referrals.

6.        Patients have the right to review their ultrasound or other test results with a physician and to receive a printed copy of those results.

7.        At the time of admission, patients have the right to be informed about the Patient Rights Policy.

8.        At the time of discharge or transfer, patients have the right to know about any required continuing healthcare.

9.        Patients have the right to participate in discussions regarding ethical issues that arise in their care.

10.     Patients have the right to be informed about any human experimentation, research, or educational projects affecting their care or treatment.

11.     Within the limits of the law, patients have the right to have their medical records kept private.

12.     Patients have the right to privacy during examinations, including the right to excuse visitors and to be informed of the presence and purpose of any observers.

13.     Patients have the right to allow or refuse another person’s presence during their care, barring extenuating circumstances (e.g., public health emergencies like COVID-19).

14.     A patient’s guardian, next of kin, or legally authorized representative may exercise these rights on behalf of the patient if the patient is:

o    Adjudicated incompetent by law,

o    Determined medically incapable of understanding the proposed treatment or procedure by their physician,

o    Unable to communicate their treatment preferences, or

o    A minor.

15.     Patients have the right to be informed about billing procedures and financial liabilities before abortion services are provided.

Patient Responsibilities

1.        Patients are responsible for providing a complete and accurate medical history to the best of their knowledge.

2.        Patients must actively participate in decisions about their healthcare.

3.        Patients should ask questions and seek clarification about their diagnosis and treatment plans.

4.        Patients are responsible for indicating whether they understand the proposed treatment and any expectations or instructions provided by healthcare personnel.

5.        Patients responsibility to promptly report any complications or symptoms related to their care.

6.        Patients are responsible for being considerate of the rights of other patients, clinical staff, and property.

7.        Patients is responsible to provide accurate and timely information about their income and financial situation if it affects their eligibility for assistance programs.

8.        Patients are responsible for paying any outstanding balances not covered by insurance, Medicare, Medicaid, or a sliding fee scale, including costs for any future medically necessary care.