3 101 RICHMOND A VENUE, SUITE 250
HOUSTON. TEXAS 77098
FAX (713) 526-0598
!, ____________ (patient), declare in the presence of Adebayo
Adesomo MD, that on this date __________ ,! am not over 70 days
pregnant. I am consenting to have the FDA approved protocol for administration of
RU-486, for chemical abortion.
________________ (signature of patient)
___________ (date patient signed)
(signature of physician) ----------------
__________ ( date physician signed)
Surburban Women's Family Planning Clinic 3101 Richmond, Suite 250 Houston, Texa 77098
Phone 713-526-6.500 ·
Name _______________________ Date _______ _
Town/Village-------.-------- State ________ County _____ _
1,-----------------------, am ________ years old, and I request and consent to the oerformance upon me of a pregnancy termination orocedure (abortion) at Suburban Women's Family Planning Clinic by Dr. Adebayo J. Adesomo or
Dr.-----------------------------
jtype or writ• in 1ha name of a phy1ici1n who will do 1he procedure 01her than thoae linadl
I also consent that said doctor may preceding, during, and following the operation perform any other procedure or reasonably indicated tests, which he deems necessary o desirable in order to per• form the abortion, or correct any other unhealthy conditions he may encounter whether or not re­ iated to the presently known condition. If any unforseen event occurs during the abortion, I further request and authorize the doctor to. do whatever he may deem advisable or necessary to protect my health, life or welfare, using his professional judgment.
I have fully and completely disclosed my medical histories, including allergies, blood conditions, prior medications or drugs taken;-and reactions that I have had to anesthetics, medicines, and other drugs .. I understand that the physician treating me is relying upon th' honest and complete dis­ closures which I have made with regard to such information.
I consent that the physician or hs associates may administer anesthesia and medic.ations as may be deemed necessary or advisable. l unBerst-and -that local anesthetics do not always eliminate all pain, that in a few cases local anesthetics may cause severe reactions, and even shock. and that no guarantee: or statement to the contrary have been made to me.
I realize that my ebonion req·uires the cooperation of technidans, assistants, nurses and other per!!lnnel; therefore, I give my fQrther consent to the administration of medications on my body by all such qualified medical personnel working under the supervision of a Doctor before, dur· ing and after this operation.
! understand that the complica.tions associated with pregnancy termination are generally much less severe than with childbirth. Nonetheless, I realize there are risks of complications .{both minor 11nd major) which may occur in this 1urgical procedure, without tlie fault of the physician. No guar• antees have been made to me that I will not suffer a complication. I understand the posibility of perforatlo,, of the uterus and .Internal injuries resulting therefrom. I understand the possibility that not all of the tissue will be removed, that fever may occur, that bleeding may occur during or after tha procedure, that infection may occur, and that I may react badly to medicines or the anesthesia; that I may h!ve pain, cramps or even convulsions, and that I may have mild or severe reactions to any of the contraceptives which I use later.
I am aware after reading the attached fact sheet and from the explanation I have received, of th, risk1 involved in an abonion and possible complications. I understand that any questions I ha.,.e wm b'e answered by my physician'and/or counselor, and that I may ask such questions before leav­
.ing the office. lf I have questions or complic·ations·after leaving the office, I agree to call the physi­ cian or oftie at 713-526-6500 immediately.
I understand that the abortioh procedure is not fully completed until I have a follow-up check up (this theck up must be before my first menstrual period ·following the procedure) by either my ohvsician er a aualified desionated clinician.
I understand that tissue and/or fetal parts will be removed during the procedure1 and mr.i I con
sent to their examination and disposal' by the technician and/or physician in the manner that the)f deem appropriate. t" k,:'IOW that the practice of medicine in surgery is not an exact science; therefore, reputable practitioners cannot guarantee results. I acknowledge ttiat no.'guarantee or assurances have been made to me by anyone regarding the operation that I have herein requested and authorized, ano furthermore, I understand that when possible, I may be treated for any resulting comp1icat1011 ?St the office at no charge to me; however, should. hospitalization be necessary, I understand that I will ue responsible for any and all charges therein.
I agree thatany dispute or claim which I may have re la.ting to the a_bortion, or any related medi cal procedure, or any of the medical personnel performing said. abortion Qr related procedure, shall be dtermined solely by a decision under the protection and protocols a.s set forth by the American Arbitration Association.
I cenify that I have read and fullv. understand the above consent to an abortion and the agree­ ment to arbitration, and that all of the above blanks or statements requiring completion are filled in, and that the information placed therein is true and correct to the best of my personal knowledge. I fully under5tand that the purpose of this procedure is to end my pregnancy and I affirm this to be my per·sonal choice. I know pr have had an explanation of other alternatives such as continuing my pregnancy to term. No one has coerced or compelled me to make this decision.
Date: Patient's signature
Dilution ond curottogo of ulorus (obstotrlcol)
1. Hemorrhage wllh poss!ble hysturoctomy lo control 2. Porforallon ol tho uterus. 3. Storllity.
Witness/Counselor 4. Injury to bowel and/or bladder. 5. Abdomlnnl Incision and operation lo correcl injury. 6. Failure to removo all products of conception.
09-5572 R 1/88
If in the opinion of a physician, hospitalization is required, t hereby ·give my consent to be transferred to a hospital.
Oate: Patient's signature
V{itness/Coun&elor
Name of Patient: -------------------------------------
r o THE PATIENT! You /Jave Iha right, es (1 pa!lenr, Co be Informed by your phystG/anfpraorwoner aoour your condiUon and /110 recommendgd surgical, mad/cal, or dlagnosllc proGodure ro be used so tflat you may maks the decision whether or not to undergo I/re procapure af!er lcnowing the rls/cs and hazards Involved. This disclosure Is not meant lo scare or alarm you: Jt Is simply an effort to make you better Informed so you may give or wllhho/d your consent to Cha procedure. ·
· Ad9bAyo J Adesomo, MD, FAOOG 1. I voluntarily raquesl Dr. ·
ae my physician, and such associates, technical assistants and other health care providers as they may deem necessary, lo treat my condition which has been eicplelned to me as: ____________ -:--------------------------------
VOLUNTARY TERMINATON OF PREGNANCY (INTRAUTERINE)
2. I understand that the follQwlng surgical, medical, and/or diagnostic procedures are planned for me, and I voluntarily consent and authorize lhm:e procedures:-------------------------------,--------
(ABORTION)
DILATION & CURETTAGE OF UTERUS WITH SUCTION ( D C WITH SUCTION .)
3, I understand that my physician may discover other or dlllerent conditions that require addll!onal or dlllerent procedures than those planned. I authorize my !)hyslclan and other health care providers lo perform such other procadures as ara advisable In their prolasslonal Judgment.
4. I (do) (do not) coneunt lo the use of blood and blood producta as deemed nocessan,. -""C"".,-- •
PT, INITIAlS
5. Any tissues or parts surgically removed may be retained or disposed of by The Msthodlst Hospital In accordance with Its accustomed praotlce.
6. I understand that no warranty or guarantee hes been made to me as to result or cure.
7. Just as there may be rlsl<S and hazards In continuing my present condition without treatment, there are also rlsl1s and hai:arcls related to tha perlormnnca of the surgical, medical, and/or diagnostic procedures planned for me. I realize that, common lo surgical, medical, and/or diagnostic procedures ls the polentlal for Infection, blood clots In veins and lungs, hemorrhage; allerglc reacllons, and even death. I olso realize that the risks am:! hazards I ln\Ual on later pages of this form, and the following rlsl<s and hezardo may occur ln connecllon with this parllcular procedure:
OTHER/ADDITIONAL RISKS: CARDIOPULMONARY ARREST NECESSITATING CPR. FATLED ABORTION CONTINUATION OF PREGNANCY.
o. I understand that onasthesla Involves additional risks and hazards, but I requeet the use or anesthetics for the relief and protocllon from pain during the planned and additional procedures. I reallze Iha anesthesia may have to be changed, posslbly without a><planatlon lo me.
9. I understand thnt certain compllcatlone may result from the use of any anesthetic Including respiratory problems, drug raacllon, paralysis, brain damage or even death, Other risks and hazards that may result rrorn the use of general anesthetics range from minor dlscomlorl to Injury to vocal cords, teeth or eyes. I understand that olhei' risks and h02ards resulting from spinal or epidural aneslheUcs Include headache and chronic pain. · ·
,::
·11. I certify this form has been fully explained lo me, that l have read It or have had It read lo me, that the b!anl1 spaces have been lilied In, and that I understand 11s contents,
Dale: ---:. ________ Time: _________ _ A,M. P,M,
Witness Name
ADEBAYO ,J. ADEBOMO . F.A.0,0.G. 3101J:UpHMOND, SUITE 250
HOUBjON, TX 77098 ·1,.
---
TEXAS DEPARTMENT OF STATE HEALTH SERVICES Sonogram and Abortion Election Form
The information and printed materials described by Section l 71.012(aXl}-{3), Texas Health and Safety Code. have been provided and explained to me. I understand the nature and consequences of an abortion.
By initialing here, I certify that I am making this decision/election of my own free will and without coercion.
Texas Law requires that I receive a sonogram prior to receiving an abortion. I understand that I have the option to decline to view the printed materials. l understand that I have the option to decline to view
· the sonogram images. I understand that I have the option to decline to hear the heartbeat. I understand that I am required by•lew to hear an explanation of the sonograrn images unless I certify in writing to one of the following:
Initial
I am pregnant as a result of a sexual assault, incest, or other violation of
the Texas Penal Code that has been reported to law enforcement authorities or that has not been reported because I reasonably believe that doing so would put me at risk of retaliation resulting in serious bodily injury.
I am a minor and obtaining an abortion in accordance with judicial' bypass procedures wider Chapter 33, Texas Family Code.
My fetus has an irreversible medical condition or abnormality, as identified by reliable diagnostic procedures and documented in my medical file.
For a woman who lives I 00 miles or more from the nearest abo1'tlo11 provider that Is a facility licensed under Chapter 245 or a facility that performs more than 50 ""'!rtlons·in any 12-month period ONLY:
I certify that, because I currently live 100 miles or more from tli«S-nearest abortion provider that is a facility licensed under Chapter 245 or a facility that performs more than 50 abortions in any 12-month period, I waive the requirement to wait 24 hours after the sonogram is perfonned before receiving the abortion procedure and understand that I must wait at least 2 homs after the sonogram is performed before the abortion procedure.
My place of residence is: ______________________ _
Signature Date
3101 RICHMOND AVE., STE. 250 HOUSTON, TEXAS noss
Waiver for women who live 100 mU.S or more from the nearest abortion provider
Place initials beside each statement and sign the bottom of the form.
_ I certify that I currently live 100 miles or more from the nearest licensed abortion provider or a facility that performs more than 50 abortions in any 12-month period.
__ I certify that, at least 2 hours prior to tM abortion, a sonogram was performed on me.
I certify that, at least 24 hours ptior to the abortion, the physician who is to perform the abortioo informed me by telephone or in person of:
__ the physician's name:
_ the particular medic;al risks associated with the particular abortion procedure to be employed: including when medically accurate:
_ the risk of infe«ion and hemorrhage; __ the potential danger to subsequent pregnancy and of infertility; and _ the possibDlty of increased risk of breast cancer foHowing an induced abortion and the
natural protective effect of a completed pregnancy in avoiding breast cancer.
__ the probable gestational age of the pregnancy at the time the abortion is to be performed; and
_ the medical risks associated with carrying the pregnancy to term.
I certify that, at least 24 hours prior to the abortion, the physician who is to perform the abortion or the physician's agent informed me by telephone or in person that:
__ medical assistance benefits may be available for prenatal care, childbirth, and neonatal care:
the father is liable for assistance in the support of the child without regard to whether the father -- has offered to pay for the abortion;
. _ public and private agencies provide pregnancy prevention counseling and medical referrals for obtaining pregnancy prevention medications °' devices; and
__ printed materials prepared by the Texas Department of Health entitled the ''A Woman·, Right to Know" booklet and the resource directory, which describes fetal clevelopment and list agencies that offer alternatives to abortion, are accessible on an Internet website sponsored by the Department, that the materials include a list of agencies that offer sonogram services at no cost to me,.
== provided me with the website address, and
PLEASE CHOOSE ONE OF THE FOLLOWING __ provided me with tne printed materials OR __ I certify that I chose to view those materials on the Internet
Signature Date
Printed Name
Hl)use Bill 15 Information Fcbru.:try 6. 2012 Pagll J
A pregnant woman may choose not t<> view the printed materials after she has been provided the mnterials.
r-1 • t ·-1 •
A pregnant woman may choose not to view the sonogram images.
A pregnant woman mny choose not to hear the heart luscultation.
· A pregnant woman may choose not to receive the verbal explanation of the results of the sonogram images only if she cer1ifies in writing on the sonogram/abortion election form. one of the following:
o the pregnancy is a result of a seual assault, incest, or other violation of the Penal Code that has been reported to law enforcement authorities or that has not been reported because she reasonably believes that to do so would put her at risk of retfliation resulting in serious bodily injury;
o the woman is a minor nnd obtaining an abortion in uccordance with judicial bypass prncedures under Chapter 33, Family Code; or
o the ftus hm, an irreversibk medical condition or abnonnality, :is medically documented in the woman's medicnl file.
In a medical emergeru:y, an ahorrion provider may perform an abortiori without obtaining a sonogram and m11st:
• include in the patient's medical record a signed statement on the medical emergency form, certifying the nature of the emergency; and
• not later than 30 days after the <late of the aborfibn, submH the medical emergency form to the Department. ·-·
• NOTE: The medical emergency fonn can be found and downloaded at the following website as of the date of this letter: http://www.ushs.st<lte.t x.us/htblapps.sb1m#abo11i{)Q.
Jftlupregnant woman decli11es to proceed with an abortion after being provided with the information req11ired by law, then the physician or agent of that physician must provide her with a state publication with iriformatir,n "" paternity establishment and child­ support ol>li_f{atlons.
A,, ,=,.,, ,I f'lnn11rrl, ,nil&, l=mnlnugr t:l,,..,.J Or.1n,irlQ;
v a6ed