NAME__________________________________________ DATE OF BIRTH_______________________
ADDRESS______________________________________ HOME PHONE__________________________
CITY__________________________ STATE___________ ZIP__________ COUNTY_________________
TDL#____________________SSN#_______________________MARITAL STATUS________________
EMPLOYER/SCHOOL___________________________________ WORK PHONE__________________
IN CASE OF EMERGENCY NOTIFY: NAME _____________________PHONE___________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * ADDITIONAL HISTORY
Were you using birth control when you became pregnant? _________________________If yes, which type___________________________________________________
Which method of birth control are you interested in for the future?
___Pills ___Diaphragm___Foam___Condoms___IUD___Sponge___ Depo Provera (Indictable)___Other____________
I HAVE ELECTED TO TERMINATE MY PREGNANCY BECAUSE_____________________________________________________________________________
_____________________________________________________________________________________
PLEASE INITIAL EACH PARAGRAPH:_____ It has been explained to me that the possible risks and complications of a pregnancy termination and dilation and curettage procedure include, but are not limited to the following:
Hemorrhage with possible hysterectomy. Perforation of uterus. Sterility.
Injury to bowel and/or bladder. Abdominal incision and operation to correct injury.
Failure to remove all products of conception. Infection Death
Increased risk of breast cancer due to lack of completion of pregnancy and not breast feeding
_____ I have had an opportunity to have all my questions answered regarding this procedure and my pregnancy.
_____ The decision to terminate a pregnancy is a difficult, complex process and I understand that some women may experience a certain degree of emotional distress.
____ I have been advised that women who have undergone multiple surgical procedures to their uterus and reproductive tract may experience some degree of impaired fertility.
_____ I have disclosed a complete and accurate medical history, including any medications or drugs taken in the last 72 hours
_____ I understand that if my procedure is not done for any reason I will be charged only for services provided, office visit, lab work, ultrasounds
_____ I have received my follow up care instructions and they have been explained to me.
____ I have viewed the HIPAA policies for the WOMEN MEDICAL CENTER OF NW HOUSTON .
____ I reviewed the written toll free number by fax or internet 24 hours prior to my surgery.
PATIENT SIGNATURE:______________________________ DATE:_____________
WITNESS SIGNATURE:______________________________ DATE:______________