Consent For Medical Abortion

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South Ave – Medical Consent Form

Consent For Medical Abortion

Medication Guide
MIFEPREX TM (mif-eh-prex) RU486 Mifeprex is an FDA-approved medication used to end early pregnancies. Early pregnancy is defined as 63 days (9 weeks) or less since your last menstrual period. Alternatively, you may elect to undergo a minor surgical procedure called a suction curettage to end the pregnancy. Mifeprex blocks a hormone needed for a pregnancy to continue. It is very effective in ending early pregnancy when combined with a second medication called misoprostol. If you take these medications and fail to abort the pregnancy, a suction procedure is strongly advised because these medications may cause birth defects. On your first visit, we will take your medical history and perform a physical exam including a transvaginal ultrasound. We will also need your blood RH typed, so if you have not provided us with blood, you will have it drawn at your expense. After reading the consent forms, you will meet with an educator who will explain the process and answer all of your questions. After receiving answers to your questions and signing the consent form, you will then take by mouth the MIFEPREX (1 tablet/200 mg). Occasional side effects include diarrhea, nausea, vomiting, headache, back pain, and dizziness. Sexual intercourse, tampons, and tub baths are not recommended for two weeks after swallowing the Mifeprex. You will also receive 4 (200 mcg) tablets of misoprostol to insert VAGINALLY over the course of the next 24 to 48 hours. You may experience cramping and bleeding for the next several hours. We recommend you insert the tablets at a time when you can rest for about 10 hours. Drink several glasses of water, and get up from a lying position slowly to avoid getting dizzy. We will give you a prescription for pain medication. Avoid Advil/Motrin/Ibuprofen during this process. Some women may experience vaginal bleeding prior to the insertion of the misoprostol. This does not mean the abortion is complete. You will still need to insert the misoprostol because this is what completes the process. If you have any questions, please call the office during the hours of 9am-4pm. Your bleeding may be similar to or greater than a heavy period. You may see blood clots, a small sac, or tissue that comes from the uterus. THIS IS AN EXPECTED PART OF ENDING THE PREGNANCY. Bleeding and spotting can last up to 30 days; the average bleeding time is 9 to 16 days. YOU MUST CALL OUR OFFICE AT (585) 271-3850 AT ANY TIME IF YOU EXPERIENCE EXCESSIVE BLEEDING, DEFINED AS SOAKING THROUGH TWO THICK, FULL-SIZE SANITARY PADS PER HOUR FOR TWO CONSECUTIVE HOURS. YOU MUST CALL IF YOU SPIKE A TEMPERATURE OF 101 DEGREES OR HIGHER, OR IF YOU EXPERIENCE EXCESSIVE DIARRHEA. You must return to our office within one to two weeks after taking Mifeprex to be sure that the pregnancy has ended. Another transvaginal ultrasound will be performed at this time. Birth control options will be discussed at this visit.
MIFEPREX TM (Mifepristone) Tablets, 200 mg PATIENT CONSENT MIFEPREX* (Mifepristone) Tablets
Patient Consent*
- I have read the attached Medication Guide for using Mifeprex and misoprostol to end my pregnancy.
- I discussed the information with the healthcare provider.
- The provider answered all questions and told me about the risks and benefits of using Mifeprex and misoprostol to end my pregnancy, including but not limited to those stated on the Medication Guide.
- I believe I am no more than 63 days (9 weeks) pregnant.
- I understand that I will take one tablet of Mifeprex by mouth in my provider’s office (1 tablet/200 mg). Side effects include nausea, vomiting, vaginal spotting, and bleeding.
- I understand that I will insert misoprostol (4 tablets/200 mcg) into my vagina at home 24-48 hours after I take Mifeprex. I understand I will experience vaginal bleeding and cramping after inserting the misoprostol. Other side effects include diarrhea, nausea, vomiting, dizziness, and fatigue.
- My provider gave me advice on what to do if I develop heavy bleeding (bleeding 2 pads/hour) or need emergency care due to the treatment.
- Bleeding and cramping do not mean that my pregnancy has ended. Therefore, I must return to my provider’s office within one to two weeks (no later than 14 days) after I take Mifeprex to be sure that my pregnancy has ended and that I am well.
- I know that in some cases the treatment will not work and the pregnancy will continue. This happens in about 1 of every 300 women who attempt medical abortions.
- I understand there is a chance that there may be birth defects if my pregnancy continues after treatment with Mifeprex and/or misoprostol. I will talk to my provider about my options, which may include a surgical procedure.
- I understand that if the medicines I take do not end my pregnancy and I decide to have a surgical procedure to end my pregnancy, or if I need a surgical procedure to stop my bleeding, my provider will do that procedure or refer me to another provider.
- I have my provider’s name, address, and phone number, and I know I can call if I have any questions or concerns.
- I have decided to take Mifeprex and misoprostol to end my pregnancy and will follow my provider’s advice on when to take each drug and what to do in an emergency.
- It is mandatory to return to South Avenue Women’s Services for a follow-up visit and ultrasound between 2 and 14 days after using Mifeprex. If I am not able or willing to return for this appointment, I cannot choose this method to terminate this pregnancy.
- By signing below, I understand that if I do not keep my follow-up appointment, I will be mailed a certified letter from South Women’s Services to remind me to return for an appointment.
- I realize I have the opportunity to discuss this procedure with a physician at South Avenue Women’s Services, and I waive this right because I feel I have been adequately informed about the procedure I have selected.
Digital Signature*
Please type your name to indicate that you read and understood the above information.
Date
Date Format: MM slash DD slash YYYY
Signature of Witness (optional)
Name
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Consent For Medical Abortion

Medication Guide