Clinic For Womenclinic4women.net/wp-content/uploads/2019/09/Medical-AB-Forms.pdf · medication...

PATIENT DEMOGRAPHICS

Revised 06/28/19 01-1a

3607 W 16th St, Ste B2Indianapolis, IN 46222-2556

P: (317) 955-2641 / F: (317) 955-2687clinic4women.net / [email protected]

Date of service________________________

PHOTOID

MEDICAID CARDSTUDENT IDMILIARTY ID

Receipt

Chart # Date

Pt. Name Age DOB

Highest Ed (circle) 8th or less / 9-11th / HS/GED / Some College / Associate�s / Bachelor�s / Master�s / Doctorate

Marital Status (circle) Married / Never Married / Divorced / Widowed / Lives With Partner

Race(s)( all that apply)

___ Black/African American ___ White/Caucasian ___ Latina/Hispanic ___ Other___ Asian ___ American Indian/Alaskan Native ___ Hawaiian/Pacific Islander

AddressEmergencyContact

City Address

ST, Zip City

County NOT Country ST, Zip

Phone ( ) Cnt. Phone ( )

Does your emergency contact know about the reason for your visit? Yes _______ No ______

Revised 05/21/19 01-1b



Payment Consent Form

I, _____________________________, understand that I am paying $200 for Prelab Services. This fee covers services provided during the first visit and the $200 is non-refundable. During this first visit, I understand that I will be scheduling the dates and times for my abortion procedure and follow-up appointment. The abortion procedure must be completed within 14 days of my first visit.

RESCHEUDLING FEES: These fees cover the costs of re-doing your lab-work, ultrasound, or administration fees. There is a $100 rescheduling fee if you reschedule your procedure appointment. It must be rescheduled within 14 days

of your initial prelab appointment. There is a $200 rescheduling fee if your rescheduled procedure appointment is more than 14 days from your initial

prelab appointment. There is a $50 rescheduling fee if you reschedule your post-op appointment. This must be completed during the NEXT

available post-op date (the next week).*NOTE: NO funding or outside resources can be used to cover any rescheduling fees.

Patient Signature Date

Parent or Guardian Signature (if patient is a minor) Date

CLINIC FOR WOMEN NOTICE OF PRIVACY PRACTICESWe respect our legal obligation to keep health information that identifies you private. We are obligated by law to provide a copy of our privacy practices. This notice describes how we protect your health information and what rights you have to that information.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health operations.

Examples of how we use or disclose information for treatment purposes are: scheduling appointments, prescribing medication, faxing medical records to a referring physician for services, or getting information from a prior health care provider.

Examples of how we use or disclose your health care information are: asking you about your health care plan, other sources of payment, preparing and sending insurance claims, and collecting unpaid balances.

Examples of how we use or disclose information for health care operations are: financial or billing audits, internal quality assurance, personnel decisions, managed care plans, defense of legal matters, business planning and outside storage of our records. This includes all operations administrative and managerial that must be performed to run our office.

We routinely use your health information inside our office for these purposes without any special permission. If we must share your health information outside of our office for these reasons we will inform you and ask for special permission.

By signing and dating below I acknowledge that I have been provided with a copy of our privacy practices.


Parent or Guardian Signature (if patient is a minor) Date

Revised 08/21/19 02-1a

SONOGRAM REPORT

Patient Name: _____________________________________________ Chart # ______________

Age _____ Est. Fertilization Date: ___________ LMP: ____________ Date of Service: ___________Patient Int.

I would like a copy of the ISDH Abortion Informed Consent Brochure. Yes No I would like to purchase a copy of my sonogram picture for $5.00. Yes No I understand the ultrasound is for gestational dating and to assure the pregnancy is in the uterus. I have received information on Available AB Counseling & Abuse/Coercion/Harassment/TraffickingCheck appropriate Box

Technique Abdominal Vaginal Measurement Gestational Age (weeks)

Planes Scanned

Longitudinal Transverse

Single Gestation

Yes Multiple

Mean SacDiameter

123

Average

cmcmcmcm

Intrauterine Yes No Crown-Rump Length

cm

Yolk sac Yes No BiparietalDiameter

cm

Cardiac activity

Yes No Femur Length cm

Patient purchased ______ sono picture(s)

PLACEPRE-LAB SONO PICTURE HERE

Gestationsl sac L+H+W (divided by) 3+30=Gestational age

PLACEPOST SONO PICTURE HERE

Prelab urine pregnancy test results: ___ Positive ___ Negative

Neg Sono/ Rtn Date and Time: _______/_______/_______, _______ am / pm

Performing Sonographer Signature: ___________________________________ Date: _______________

Physician Review: __________ Adequate __________ Inadequate __________ Referral

Physician�s Signature: _________________________________ Date: ________________

RHSTICKER

ALLERGYSTICKER



ABORTION FETAL ULTRASOUND AND HEART TONE CERTIFICATION State Form 55321 (R3 / 6-18) INDIANA STATE DEPARTMENT OF HEALTH – IC 16-34-2-1.1(a)(5)

INSTRUCTIONS: Before an abortion is performed, the provider must perform a fetal ultrasound and fetal heart tone procedure. The provider must enable the pregnant woman to view the fetal ultrasound image and hear the heartbeat of the fetus, if the fetal heart tone is audible. The purpose of this form is to document your opportunity to view the image and hear the heart tone. In this form, “abortion” refers to either a surgical abortion or a medication abortion (abortion resulting from an abortion inducing drug). The completed form is kept by the provider as part of your medical record.

I affirm that this form is being completed prior to the abortion.

The abortion provider has offered me the opportunity to view the fetal ultrasound image. I selected the following (check the appropriate selection):

I wish to view the fetal ultrasound imaging that will be done prior to the abortion.

I decline to view the fetal ultrasound imaging that will be done prior to the abortion.

The abortion provider has offered me the opportunity to hear the auscultation of the fetal heart tone, if the fetal heart tone is audible. I selected the following (check the appropriate selection):

I wish to hear the fetal heart tone, if audible prior to the abortion.

I decline to hear the fetal heart tone, if audible prior to the abortion.

I hereby certify that information has been provided to me as indicated above.

Printed name of patient Patient’s medical record number

Signature of patient Date (month, day, year) Time

Alisha

02-1b

Alisha

am / pm

Revised 08/21/19 03-1a



*FOR CLINIC USE ONLY: SURGERY REPORT

Patient Name ____________________________________ Date of service________________________ Chart# __________________

Here today with:________________________________ SMOKER / NON-SMOKER Age _____________SONO RESULTS WKS DAYS TECH INIT SONO DATE

1st Sono result2nd Sono result

Check here if this surgery is a result of a FAILED/INCOMPLETE ABORTION. PATIENT HAS BEEN TO THE LAB TODAY FOR POST-OP VISIT: ________ (staff INT)

Contraception Choice: None / OCP / Nuva Ring / Ortho Evra / Depo Provera / Other: _______________________________

Physician�s Order(s): Pre-Operative Medication(s): Time given: Staff Init□ Metronidazole 500mg □ Amoxicillin ... 500mg □ Other am / pm□ Naproxen ........ 500mg □ Ibuprofen..... 800mg □ Tylenol.... 500mg □ Other am / pm□ Cytotec............400mcg, buccual □ Other am / pm□ Valium ............5mg □ Valium .........10mg □ Other am / pm

Physician Record: Examination: The attending physician has reviewed the patient�s current medical history

Uterine position: □ Antiverted □ Retroverted/Flexed □ Mid

Gestational size: _______ wks Determined via Bimanual / Sono Adnexa: Normal / Abnormal

INSPECT/Narcotic and pre-anesthesia evaluation review date: / / Physician Initials: , M.D.

SOI Given / / am / pm

SOI PLUS 18 hours / / am / pm

Procedure: Start time: ______________ am / pmAnesthesia: □ Lidocaine 1% Total ml _______ Application: □ Paracervical □ IntracervicalMethod: □ Dilation and Suction □ Curettage □ Sharp Curette ________ / Cannula/Curette size _____________________mm

Procedure: Time Completed: ______________ am / pmPost-Operative Medication(s): Specimen Tech Initials............□ Methergine 0.2mg upon recovery; IM Tissue Sac................................. Y / N

□ MICRhoGAM IM Chorionic Vill ............................. Y / N

□ Contraception: ________________________________________ Fetal Parts ................................. Y / NEctopic Watch ........................... Y / N

□Other: _______________________________________________ Specimen to CYTO/PATH......... Y / N

Physician�s Orders: RH / HCT / UA / HCG Patient is in stable condition after receiving local anesthetic during the surgical abortion procedure and is discharged to and from the post anesthetic care unit. I have also reviewed the specimen with Specimen Tech to verify presence of the tissue/parts indicated above.

Physician�s Signature: _______________________________________ Date:_______________________________

ALLERGYSTICKER RH

STICKER

RECOVERY NOTES

Revised 08/21/19 03-1b



Date__________________________

Pt. Name___________________________________________ Chart #________________________

Allergy Problems__________________________________________________________________________________Current Medications________________________________________________________________________________

Admission to Recovery______________ am / pmVitals: B/P ______________ Pulse_____________ _______________ am / pm

______________ _____________ _______________ am / pm 3rd B/P if prior B/P elevated ______________ _____________ _______________ am / pmGeneral Physical Condition:Skin: clammy cold dizzy dry hot light-headed nauseous ok pale sweaty warm

Assessment scale Cramping on admission: (Circle one): None Light Moderate Heavy Vomited: est._____cc _________am/pm

Pre-operative medication(s): □ Valium: 5mg / 10mg □ Ibuprofen 800mg □ Naproxen 500mg □ Tylenol 500mg □ Cytotec 200mcg #2 buccal □ Metronidazole 500mg #1 po □ Amoxicillin 500mg #1 po

Medication Administered:□ Atropine IM: lot#__________ Exp Date___________ Site__________ □ Methergine Maleate 0.2mg: IM: lot#__________ Exp Date___________ Site__________ □ Immune Globulin; mini dose IM: lot#_____________________ Exp Date_______________ Site________________ □ Depo-Provera: Lot # ________________________ Exp Date _____________________ Site __________________□ Other _________________________________________________________________________________________ Medication Dispensed/Ordered:□ Contraception x _____ cycles: Nuva Ring/Ortho Cyclen/Ortho Tri-Cyclen/Other_______________□ Other: _________________________

□ Dispensed written and oral post-operative instructions, including administration, side effects, and contraindication of all medications received and after-hours telephone number□ Scant tissue/Ectopic warnings given

□ Post-Op follow-up: □ Will call with pregnancy test results □ Post-Op with own doctor □ Undecided

Patient Assessment scale: Vaginal Bleeding: Circle: None, Scant, Light, Moderate, Heavy Pad Count ________Cramping: Circle: None, Light, Moderate, Heavy General Condition of Patient:_________________________________________________Against Medical Advice:____________________________________________________Emergency Transport Needed: __Yes __NoPatient is stable and ambulatory. She may be discharged from recovery per Physician�s order, unless indicated otherwise. Discharge from Recovery: ___________am/pm

Patients read and sign prior to leaving. (Pacientes: Lea y firme antes de salir)I have been given a copy of the abortion aftercare instructions and the after-hours contact number (317) 955-2641 to take home. They have been explained to me and I agree to follow them. My failure to follow them releases Clinic for Women from any liability or responsibility for my care. (Me han dado una copia de las instrucciones para mi cuidado despues de mi cirugia. Las entiendo y si no las sigo, la clinica no tiene la responsibilidad de mi cuidado ni de mi salud.)

__________________________________/_________________ _______________________________________Patient Signature (Firme de paciente) / Date Recovery Attendant Signature

________________________________________________________Parent/Guardian Signature (Si menor de edad, firma de paciente)

Revised 06/28/19 06-1



PATIENT CONSENT FORM FOR TERMINATION OF PREGNANCYDO NOT SIGN UNLESS YOU FULLY UNDERSTAND THE FOLLOWING

1 I, _______________________________ am ____ years old. I request that an abortion, which is asurgical procedure to end my pregnancy, be performed on me by _________________________, a contract physicianwith Clinic for Women (CFW).

INSTRUCTIONS TO PATIENT: Please put your initials in each parenthesis as you read, understand, and agree:

( ) 2 I have made this decision to have an abortion because I do not want to have a baby at this time. I know my other choicesare giving birth and adoption, but abortion is my personal choice. No one is forcing me to choose abortion, it is mydecision.

( ) 3 I have told all of my past and present medical history, including allergies, blood conditions, prior medicinesand drugs taken, also any adverse reactions to anesthesia, medicines, or drugs. I understand that a full and completedisclosure of my medical history is important to help minimize the risks of complications which may occur with an abortion.I understand that the physician of CFW is relying on my information to be truthful and complete.

( ) 4 The first day of my last normal period was _______________, 20____.I have described in today's medical history any unusual characteristics of this period because I realize this information isimportant in determining how far into my pregnancy I am and whether an abortion can be done in an outpatient clinic in Indiana. The physician's decision to proceed with the abortion is based on the aboveinformation as well as findings from examination and possible ultrasound.

( ) 5 I give my consent to be given local anesthesia or pain medicine except _______________________________________.I understand that local anesthesia does not eliminate all pain, and that in a small number of cases, patients could have asevere allergic reaction to a local anesthetic including shock, or even death.

( ) 6 I give my consent to the taking of cultures, smears and other medical tests that the physician feels is appropriate ornecessary. I understand that tissue and/or fetal parts will be removed during the abortion and I give my permission forthem to be disposed of according to state law.

( ) 7 I understand that there are risks of both major and minor complications which may occur with this, as with all surgicalprocedures. No guarantee has been made to me. These complications can include, but are not limited to, perforation ofthe uterus (putting a hole through the uterine muscle) or damage to the cervix, uterus or adjacent organs, hemorrhage(severe bleeding), retained tissue and/or infection, all of which could be severe enough to require surgery resulting inhysterectomy (removal of the uterus), and/or sterility (never being able to become pregnant again), or even death. If any ofthe above reactions or complications do occur, I further realize that I may need to be hospitalized which would be at myown expense. I realize that such complications can be caused by other medical conditions not related to the pregnancytermination procedure and/or by my failure to follow postoperative instructions, or by the treatment of the follow-upphysician.

( ) 8 Should I require hospitalization or medical treatment by a physician not affiliated with CFW for any reason related to thisabortion, I now give my permission for the release of all medical records associated with such care. I understand that I amgiving my permission prior to such care.

( ) 9 If an unforeseen condition or complication arises during the abortion which in accordance with good medical practice callsfor a different or additional treatment, I give the physician permission to do whatever in her/his professional judgment isnecessary. Examples of such treatment are: the administration of IV fluids, the use of ultrasound during the abortion,repair/suturing of a cervical tear.

( ) 10 I fully understand that there is no guarantee that this abortion will terminate my pregnancy. Which could result incontinuing pregnancy or incomplete abortion requiring an additional procedure or other very rare complications includingdeath. Therefore, it is very important that I have a post-abortion check-up within 4 weeks to be certain that I am nolonger pregnant and that no other medical problem has occurred of which I may be unaware.

11

Revised 06/28/19 06-1



( ) 11 I have had full opportunity to ask questions about my abortion and the risks and alternatives involved and am satisfied withthe answers. I understand that any further questions I may have will be answered before I leave the clinic -1 have only toask them. I understand that it is my responsibility to bring to the attention of CFW any post-abortion problems I mayencounter. The problems could include fever, heavy bleeding, severe cramping or pain, unusual or foul smellingdischarge, or the absence of a normal period within six weeks of the procedure. I realize that, should any such problemsarise, immediate treatment may be necessary to avoid more severe complications. I also realize that any questions I haveafter leaving the clinic today can be answered by calling CFW, since our telephone is answered 24 hours a day, sevendays a week.

( ) 12 I understand that problems that after an abortion are rare. If the problem can be resolved in the clinic or by calling theclinic for instruction these services are provided without further cost to me. It is MY responsibility to adhere to all of myfollow up appointments and contact the clinic if there are any issues. The clinic reserves the right to refer me to an outsidephysician if they cannot resolve the problem in the clinic OR if the issue is past a reasonable post-op time frame. I will beresponsible for associated costs. I also understand that if I do not contact CFW, but instead go to an emergency room oranother doctor for care, CFW cannot be responsible for any costs or treatment that results.

( ) 13 I understand that following an abortion I may experience feelings of regret and/or depression - emotional distress. I havebeen told that resolution of my feelings prior to the abortion procedure is the best protection from emotional distress post-operatively. I have had an opportunity to fully discuss my feelings about this pregnancy and impending abortion and amcomfortable with my decision to terminate this pregnancy. I wish to schedule additional time for discussion of emotions/feelings associated with this abortion before or after the procedure:(Please circle one) Yes No

( ) 14 I understand I have the right to determine the final disposition of my aborted fetus. I have informed Clinic for Women inwriting and have completed and submitted the form prescribed by the Indiana State Department of Health of my decisionfor disposition of my aborted fetus before it may be discharged from the clinic. Also, I understand that it is myresponsibility to provide the container for my aborted fetus. I understand Clinic for Women must obtain parental consentif I am a minor, unless I have received a waiver of parental consent under IC 16-34-2-4. I understand Clinic for Womenwill release my aborted fetus to me as long as I have completed the required forms, provided a container for my abortedfetus, and have paid the processing fee of $300.00. I would like to take my aborted fetus with me.(Please circle one) Yes No

( )minor

15 I am a minor who has gone through the Judicial Bypass procedure. I understand that it may still be necessary to contactmy parent or legal guardian to get consent from that person in the event of an emergency or a complication that requireshospitalization.

I certify that I have read (or have had read to me) and fully understand the above consent form regarding my abortion, that theexplanations therein referred to were made and that I completed all blanks or statements.

DO NOT SIGN UNTIL YOU HAVE COMPLETELY READ AND FULLY UNDERSTAND THE ABOVE.

PATIENT�S SIGNATURE __________________________________________________ DATE _______________________

PARENT SIGNATURE, if patient is a minor ____________________________________ DATE _______________________

STAFF SIGNATURE ______________________________________________________ DATE _______________________

I give permission for release of my records from Clinic for Women to:

Name (Doctor or Clinic) _______________________________________________________________________________

Address____________________________________________________________________________________________

PATIENT�S SIGNATURE _______________________________________________ DATE _______________________2

Revised 05/21/19 07-1a



Patient Name _________________________ Pt# ____________ Phone ______________

Date Nurse / Staff : Patient Notes

PATIENT MEDICAL HISTORY

Revised 09/09/19 07-1b



Pt. Name Chart #Date Age DOB

Medication Allergies:Current Medications:Do you smoke or use nicotine products? .................................................... N / Y ________ pks/day* Have used marijuana or illegal substances in the past 48 hours? .......... N / Y Which drugs? ....* Have you consumed alcohol in the past 48 hours? .................................. N / Y* NOTES:Have you ever had vaginal or abdominal surgery in the past 3 months? .. N / Y When?...............

-What procedure did you have done? ..................................................GYNECOLOGICAL HISTORY

PREVIOUS number or �0�: Vag Births C-sections Ectopic preg Miscarriages Abortions

List any problems with pregnancies.....Name of your gynecologist or phys .....First day of last normal menstrual pd...Are your periods usually..............................heavy moderate lightAre your cramps usually..............................none mild moderate severeHow often do your periods occur..........every _________ days OR irregular My periods usually last: _________ days OR irregular

What birth control were you using when you got pregnant?Date of last physical exam.................... Any Issues? ....... N / YDate of last pap test.............................. Was it normal? .. N / Y

Have you ever had any of the following? (Circle the correct response.) Please explain all �yes� answers, including when it occurredBlood clots in legs, lungs N / Y Gonorrhea or Chlamydia...................N / YPID or Pelvic Inflammatory Disease..............N / Y Venereal Warts or Herpes ......................N / YBlood transfusion...........................................N / Y Major surgery .......................................N / YHeart Murmur/Mitral Valve Prolapse ............N / Y Serious illness....................................N / YProblems with contraception .........................N / Y

Have you or any of your family had any of the following? (Check only if it applies)CONDITION Self Mother Father CONDITION Self Mother FatherHeart disease/attack .......................... □ □ □ Psychiatric treatment............................ □ □ □High blood pressure ........................... □ □ □ Drug/Alcohol Addiction treatment......... □ □ □Thyroid disease.................................. □ □ □ Hepatitis/Liver Disease/Mono .............. □ □ □Blood clots .......................................... □ □ □ Breast disease ..................................... □ □ □Diabetes/Sugar .................................. □ □ □ Asthma ................................................. □ □ □Fainting spells..................................... □ □ □ Respiratory problems ........................... □ □ □Epilepsy/Convulsions/Seizures .......... □ □ □ TB or lung problems............................. □ □ □Migraine headaches ........................... □ □ □ Cancer: ___________________ ......... □ □ □Stroke/Numbness ............................... □ □ □ Fibroids/Cysts ....................................... □ □ □Adrenal disease................................. □ □ □ Ovary/Fallopian Tube problems............ □ □ □Abnormal Vaginal Discharge .............. □ □ □ Infection of Ovary/Tube/Uterus ............. □ □ □I understand that misrepresenting my medical history and current medical status could result in surgical and/or medical complications. By my signature I declare the above information to be truthful.


Staff Signature Date

Revised 06/30/19 10-1a



EMOTIONAL HEALTH AND PATIENT EDUCATION

Patient Name __________________________________________________________________ Date ____________________

Patient Emotional Health Questionnaire: Patient please answer questions 1-10.

STOP: Below this line is for Clinic Use Only: ****PATIENT EDUCATION****

Group Education: Patient has received education about the procedure, recovery, and aftercare instructions:

*Staff Signature: _______________________________________ Date: _____________________ Time:___________ am/pm

Individual Education:1. Procedure, Recovery, and Aftercare patient questions/concerns: ...NONE / Answered in Group / Questions/Concerns Below:

2 CFW Contraception Choice: ................................................................ None / OCP / Nuva Ring / Ortho Evra / Depo3 Other choice (if applicable, ie: physician) ............................................ _________________________________________4 Available contraceptives discussed and signed?................................. Y / N5 Discussed other options of birth control? ............................................. Y / N condoms / spermicide /6 AB consent form signed: ..................................................................... Y / N7 Based on my conversation with this patient she is okay with her decision Y / N8 If NO for #7, Outsource Referral list given? ....................................... Y / N

Patient has received education about birth control, conflictions, after-care counseling, and been able to ask any questions:

*Staff Signature: _______________________________________ Date: _____________________ Time:___________ am/pmPhysician Consult

1. Have you have considered options other than abortion? ..............Y / N If YES for #1, what other options did you consider? ................_________________________________

2 On a scale of 1-10 (1=easy, 10=very difficult) how easy was this decision?...........1 2 3 4 5 6 7 8 9 103. Whose decision is it for you to have this abortion?........................Self / Partner�s / Other: 4. Have you discussed your decision with anyone? With whom?.... Y / N _________________________5 Name AND Age of father involved in this pregnancy? .................._____________________, AGE______6. Does father know of your decision? ..............................................Y / N 7. Does father support your decision? ...............................................Y / N / Not Applicable8. Please circle all the words that describe how you feel

confident relieved trapped conflicted unsure sad scared confused resolved guilty selfish numb nervous angry

9. Please check off the items below that concern you the most todayWhether abortions are safe Fetal development If I will be able to have children laterSomeone is forcing/pushing me to do this How I�ll feel emotionally after the abortion

10 Are you seeking an abortion as a result of being abused, coerced (forced), harassed, or trafficked? Y / N


Parent Signature (if patient is minor) Date

Staff Signature Date

Revised 06/30/19 10-1b



AVAILABLE CONTRACEPTIVES &CONTRACEPTIVE CONSENT FORM

Clinic For Women offers the following birth control options:1. Birth Control Pill2. Nuva Ring3. Ortho Evra �The Patch�4. Depo Provera

Factors to be considered: Recently published scientific studies have indicated that there probably is an increased risk of developing serious circulatory disease, including heart attack, in certain women with high risk factors who use contraception containing ESTROGEN. Although heavy smoking appears to contribute the greatest risk, each health factor acts to multiply a woman�s risk.

The following list contains the current medically recognized risk factors. Those risks that in your case may increase the possibility of developing serious complications while using oral contraceptives.

PERSONAL or FAMILY History of:

Smoking Hypertension Heart attack under age 50 in one or both parents 35 years old and older High Cholesterol Deep Vein Thrombosis (blood clots in arteries) Overweight or obese Diabetes; parents, siblings

However, some women experience these additional benefits from using Oral contraception:

Predictable periods, lighter bleeding, and/or decreased cramps Decreased ovarian cysts, endometrial cancer, and/or ovarian cancer Skin improvement; acne

I understand and agree to the following:a. It is my responsibility to make and keep regular appointments with my Health Care Provider as required for

continued birth control evaluation or options.b. It is best to stop using hormonal contraception at the end of the complete cycle or one month. However, if I wish to

stop, I may do so at any time during the month. I understand, I may experience sporadic (on and off bleeding), or irregular periods.

c. I am aware of the contraceptives that Clinic For Women has to offer AND have been given DIRECTIONS FOR USE as well as information about the RISKS, WARNING SIGNS & SIDE EFFECTS associated with my choice.

d. If I do not want any of the contraception offered by Clinic For Women, information about other available birth control options will be provided to me if I desire.

I would like additional information on: _________________________________________________________

Revised 08/05/19 M-1a



MEDICAL ABORTION CHECKLIST

Patient name ________________________________________ Chart # _____________

Completed by DateSono:

W D2nd Sono:

W DPatient meets inclusion & exclusion criteria

Possible risk & complications explained

Patient instructions & procedure explained

Follow up schedule explained

Consent form signed and witnessed

Smoker Y or N

Possible necessity of surgery procedure

Wt Tmp B/P P Rh Hct

LAB1

Physician’s Orders

LAB2 , MD

Time Admin By / Physician Date

Ondansetron (Zofran) 8mg PRN am/pm , MDPatient dispensed four tablets of Misoprostol 800mcg to insert buccally , MD200 mg Mifeprex administered to patient to swallow am/pm , MD

Patient given Rx for ten tablets of Norco 5mg/325mg , MD

INSPECT REVIEW DATE , MD

, MDImmune Gobulin: mini dose IM: Administration & Physician Order Lot # Exp Date Site

Contraception Disp/Ord: None / OCP / Nuva Ring / Ortho Evra / Depo Provera , MD

Other Medication: , MD

Pt told to return for exam on / / am / pm

ALLERGYSTICKER

RHSTICKER

Patient signature: ____________________________________________ Date ___________________

Parent signature: _____________________________________________ Date ___________________

Witness: __________________________________________________ Date ___________________

Revised 09/06/19 M-1b



Medical Abortion Inclusion and Exclusion Criteria

Name________________________________ Date________________ Chart # _____________

INCLUSION criteria- to qualify, patient must answer yes to all of the following:

1) Good general health yes no

2) Willing to have a surgical abortion if necessary yes no

3) Pregnancy no more than 70 days (10 weeks) gestation yes no

4) Agrees to: vaginal ultrasound, venipuncture, pelvic exam yes no

5) Willing and able to sign informed consent yes no

6) Access to a telephone and emergency transportation yes no

7) Willing to comply with visit schedule yes no

EXCLUSION criteria- to qualify, patient must answer no to all of the following:

1) Confirmed or suspected ectopic pregnancy yes no

2) Adrenal failure yes no

3) Chronic systemic corticosteroid therapy (inhaled corticosteroid only can still use) yes no

4) History of allergy to mifepristone, misoprostol, or other prostaglandins yes no

5) Current anticoagulant therapy yes no

6) Hemorrhagic disorders yes no

7) Inherited porphyrias yes no

8) IUD in place (must be removed prior to abortion appointment) yes no

1. I have decided to take Mifeprex 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 Mifeprex 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 Mifeprex.

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 Mifeprex 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 Mifeprex 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 Mifeprex. I will take it with me if I visit an emergency room or a healthcare provider who did not give me Mifeprex so that they will understand that I am having a medical abortion with Mifeprex.

10. My healthcare provider has answered all my questions.

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

Patient Agreement:

03/2016

PATIENT AGREEMENT FORM

Patient Signature: Patient Name (print): Date:

The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered all her questions.I have given her the MEDICATION GUIDE for Mifeprex.

Provider’s Signature: Name of Provider (print): Date:

After the patient and the provider sign this PATIENT AGREEMENT, give 1 copy to the patient beforeshe leaves the office and put 1 copy in her medical record.

*MIFEPREX is a registered trademark of Danco Laboratories, LLC.

Alisha

Revised 03/2016

Alisha

M-2a

Revised 05/22/19 M-2b



To all patients considering a Medical abortion:

If you have any condition that requires long term use of steroids, the use of Mifeprex and Misoprostol to terminate your pregnancy would not be safe for you.

If your immune system is deficient or compromised in any way, such as being HIV positive or diagnosed with Lupus, you would not be eligible for a Medical abortion.

I have read and fully understand the above statement.

__________________________________________ _____________________Patient signature Date

Ondansetron (Zofran) is a very effective anti-nausea medication with minimal reported significant side effects.

Side effects of Ondansetron have generally been infrequent and mild including: diarrhea, headache, fatigue, and constipation.

NOTE: If you vomit the Mifeprex, which will be administered by the physician, you must repurchase it $100 in order to complete your medical abortion.

I would like to receive 8mg of Ondansetron to reduce risk of nausea and/or vomiting free-of-charge.

Yes____ No____

__________________________________________ _____________________Patient signature Date

__________________________________________Witness signature

Medical Abortion Consent Form

Revised 08/05/19 M-4



I ______________________________give my permission for Dr.___________________________ and/or such associates s/he may elect and supervise to perform a nonsurgical/medical abortion with Mifepristone and Misoprostol. I understand that I am up to ten (10) weeks pregnant, and I have decided to have an abortion with the medications Mifeprex and Misoprostol. These medications will cause an abortion by starting vaginal cramping and bleeding similar to a very heavy period or miscarriage. This method allows a pregnant woman to have an abortion without putting instruments into the uterus.

Mifeprex is a drug that blocks the action of progesterone, a hormone needed to continue a pregnancy. Misoprostol is a drug which causes the uterus to contract and empty. When the FDA approved Mifeprex, it was approved for use in combination with Misoprostol. Studies have shown that Mifeprex and Misoprostol, when used together, are approximately 95% effective in causing an abortion in an early pregnancy.

Procedure:This procedure follows the evidence based regimen- a process that has been thoroughly studied for over 10 years and allows the patient to complete her nonsurgical abortion using less Mifeprex and with fewer clinic visits than the FDA regimen. The evidence based regimen has been proven effective, is less expensive, and has fewer side effects- particularly stomach upset and diarrhea.

1. After a thorough medical history I will have an ultrasound to confirm the gestation of the pregnancy to make certain it is 10 weeks or less.

2. The physician will review my history, ask any questions s/he has, and may perform a pelvic exam.3. The physician will give me 200mg of Mifeprex to swallow while here in the facility.4. I will be given 4 Misoprostol tablets with instructions to regarding the placement of the 4 tablets5. I will plan to stay home for approximately 6-8 hours after placing the Misoprostol tablets. I can expect to have

moderate to severe cramping and vaginal bleeding in the hours following the placement of Misoprostol.6. I will contact my provider at 1-800-545-2400 if I soak two maxi pads per hour for two consecutive hours. 1 will take

my temperature the day after placing the Misoprostol and contact the Clinic for Women if it exceeds 100.4 degrees. 7. I will contact my provider right away if I have treated my fever of 100.4°F or more with Tylenol that persists for

more than 2 hours.8. I will contact my provider right away if I have heavy bleeding (soaking through two thick full-size sanitary pads per

hour for two consecutive hours).9. I will contact my provider right away if I have abdominal pain or discomfort including weakness, nausea, vomiting or

diarrhea, more than 24 hours after taking misoprostol.10. Take the MEDICATION GUIDE with me when I visit an emergency room or a provider who did not give me

Mifeprex, so that they will understand that I am having a medical abortion with Mifeprex.11. Return to my provider’s office about 7 days after beginning treatment to be sure that my pregnancy has ended and

that I am well.12. If I have severe abdominal cramping, I know that I can take pain medications which do not contain aspirin such as

Ibuprofen and Aleve.13. I will return to the clinic approximately 7 days for my third visit for the purpose of having a vaginal ultrasound . 14. If the pregnancy has not been terminated, I understand that I may need to have a surgical abortion.

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Medical Abortion Consent Form

Revised 08/05/19 M-4



Risks may include:

Incomplete abortion; As with surgical abortion, some pregnancy tissue may remain in my uterus. If this occurs, the provider will discuss my treatment options, which may include a surgical abortion. The risk of having very heavy vaginal bleeding after using Mifeprex and Misoprostol is about 1/100 or 1%. The risk of needing a blood transfusion after using these medications is about 1/1000 or 0.1%.

Continued pregnancy and birth defects: My pregnancy may not end after receiving the medications. If this happens, birth defects are possible. Because of the risk of birth defects, I know that a surgical abortion is strongly recommended to end the pregnancy. The risks of a first-trimester surgical abortion include perforation of the uterus, tearing of the cervix, an adverse reaction to any anesthesia used, infection, excessive bleeding, and failure to remove all of the tissue from the uterus.

Side effects: The following side effects are possible: nausea, vomiting, diarrhea, fever, headaches, and chills. Most of these side effects last less than a day. Expect cramping in lower abdomen and you may need pain medication.

Pregnancy complications: Ectopic pregnancy or a pregnancy outside the uterus is a rare condition. It is a complication of pregnancy rather than abortion. I understand that if the pregnancy is in the fallopian tube or outside the uterus, neither surgical abortion nor Mifeprex/Misoprostol abortion will remove the pregnancy. Due to the possible threat of rupture of the fallopian tube, hospitalization may be necessary as soon as it is discovered.

The CFW fee for a medical abortion includes payment for a surgical abortion if needed. The fee does not include charges for an emergency room visit or for care at another facility.

Voluntary Consent

I have been informed of other choices during early pregnancy including continuing the pregnancy and becoming a parent, continuing the pregnancy and making adoption arrangements, and surgical abortion. I have been informed of the risks involved with a surgical abortion and a medical abortion, and the risks involved with continuing the pregnancy. I understand that I may choose to have a surgical abortion at any time after I start the medical abortion, although I will need to pay for this care if it is not medically necessary.

I have fully disclosed my medical history including the date of my last menstrual period, allergies, blood conditions, prior medications or drugs, and reactions to medications or drugs. I certify that I have read this form or it has been read to me. I understand its contents, and any questions have been answered to my satisfaction. I certify that 1 have been given the Mifeprex Patient Agreement and that I have had an opportunity to read it and discuss it with my provider.

I have been given a copy of the abortion aftercare instructions and the after-hours contact numbers: (317) 955-2641 or (800) 545-2400 to take home. They have been explained to me and I agree to follow them. My failure to follow them releases Clinic For Women from any liability or responsibility for my care.

_________________________________________ _________________ _________am / pmPatient Signature Date Time

_________________________________________ _________________ _________am / pmParent or Guardian Signature, if patient is a minor Date Time

_________________________________________ _________________ _________am / pmWitness Signature Date Time

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Revised 08/05/19 1 of 4 M-3



MEDICAL AB INSTRUCTIONS: Please bring this form with you when you return for your second appointment:

You are going to return to CFW on _______________________, ____/______/_______ at ____________ am / pm with $____________. (Day) (Date) (Time) (cash) There is a 15 minute grace period for your appointment time. If you are more than 15 minutes late you will be assessed a late fee or given the option to reschedule you still meet the gestation requirements. Please note if you have to reschedule, you may no longer qualify for the medical procedure.

Please make sure you wear a maxi pad to this office visit. On your return visit, you are going to take the following medication:

1) Ondansetron (Zofran) PRN - Please let the staff know if you feel nauseous, and you will be administered this medication.2) Mifeprex-stops the growth of your pregnancy, it may cause cramping and you may begin to spot. Note: It takes 30 minutes

for this medication to enter your system and become effective. If you leave the clinic, are unable to keep this medication down, and need to take an additional Mifeprex tablet you are responsible for the additional $100.00, replacement fee.

You will be sent home with the following medication and prescription (Rx at Dr. Discretion ONLY):

(1) Misoprostol-please insert the four tablets of misoprostol, buccally. This means to insert into your mouth between your cheek and gum. Place two tablets on each side of your cheek. Until dissolved, do not eat or drink any liquids. The misoprostol tablets must be inserted into your cheeks within 24 to 48 hours.

You may insert the tablets as early as _________am / pm on ___________________, _____/______/______.

The tablets must be inserted into your cheeks by _________am / pm on ___________________, _____/______/______.

(2) Norco 5mg/325mg or Tylenol #3 (Rx at Dr. Discretion ONLY)-The Physician will discuss pain medication options with you. S/he may suggest an over the counter pain medication regimen or s/he may write you a prescription for ten (10) tablets of Norco 5mg/325mg or Tylenol #3. It will help relieve the cramping during your procedure. Please use medication wisely - NO REFILLS.

The medical abortion procedure requires that all patients have two vaginal ultrasounds. Your first ultrasound was done on

____________________________________. Your follow up vaginal ultrasound is scheduled for ______________, _____/______/______ at _________am / pm.

The purpose of the second ultrasound is to be certain that the pregnancy was terminated. For some women, even if they have had bleeding, the abortion may not be complete. If the pregnancy is still growing at the time of your follow-up visit, it is strongly recommended that you have a surgical abortion (using suction) because the medication can cause birth defects in this pregnancy if it continues. PLEASE NOTE: If you do not return for your second ultrasound, Clinic for Women will consider your failure to have the second ultrasound as a breach of contract between you and Clinic for Women. At that time we will close your file and will not attempt to contact you again regarding this matter. We can also provide you with contraceptive information if not provided at your first appointment. Please sign below to confirm you received a copy of this letter and as well as a copy of your instructions.

_________________________________ _________________ __________am / pmPatient Signature Date Time

_______________________________________ ___________________ ___________ am / pmParent Signature, if patient is a minor Date Time

_________________________________ _________________ __________ am / pmStaff Signature Date Time

____ Time

Revised 08/05/19 2 of 4 M-3



MEDICAL ABORTION TEACHING

Below are instructions for your medical abortion care. Please save this sheet to refer to if you have any questions. Call the clinic at 1-800-545-2400 if your questions are not answered on these sheets. Our office hours are Monday through Friday, 9:00am to 5:00pm, and some Saturdays 7:30am to noon. Our answering service is available 24 hours a day to have a staff member paged.

Your First Clinic Visit You will an ultrasound to determine eligibility for a medical abortion. You will receive your state ordered information which is required by Indiana law. You will receive patient education about what to expect during the medical abortion process. You may discuss birth control options with a staff member at this time.

o With the physician’s approval, you may receive a prescription for a one month supply of either birth control pills or the NuvaRing, along with one refill. At the time of your check-up you will be informed regarding the start date of your birth control.

o If you want the Depo-Provera Injection the cost is an additional $100.00 and you will receive your injection at your follow up visit.

Your Second Clinic Visit

You will have routine lab work completed. If your blood type is RH negative you will need a rhogam injection which is an additional $50.00.

You will see the doctor to take Mifeprex. This medication causes the pregnancy to stop growing. Mifeprex works by blocking the action of progesterone, a hormone needed to continue a pregnancy. It is used in combination with Misoprostol, a drug that causes the uterus to contract and expel the pregnancy. After taking Mifeprex the abortion process has begun, you will probably feel no different after taking the Mifeprex; however, you may experience nausea or vomiting. In some cases, some women start to bleed and cramp before the Misoprostol is placed between your cheek and gum.

Medications taken at home:

o Misoprostol 800mg (4 tablets)To be inserted buccally (between cheek and gum) (24 to 48 hours after taking Mifeprex)

o Norco 5mg/325mg or Tylenol #3 (10 tablets) (Doctor's discretion only)For pain: please take your first dose of pain medication forty-five minutes before you place the four (4) tablets of misoprostol into your mouth buccally. You may also take any non-aspirin, over the counter pain medication for discomfort or pain. Non-aspirin medications: Motrin (Ibuprofen) or Aleve (Naproxen Sodium). For pain management, take pain relievers as directed, every 4 to 6 hours around the clock. TYLENOL DOES NOT WORK FOR CRAMPS!

Revised 08/05/19 3 of 4 M-3



How to Insert the Misoprostol:

Insert all four (4) tablets of Misoprostol buccally 24 to 48 hours from the date and time of taking the Mifeprex. To insert buccally, place two Misoprostol tablets on each side of your mouth, between your cheek and gum. Be prepared to spend this day and possibly the next day at home. You should have your SUPPORT person with you until abortion is complete or until the bleeding and cramping is tolerable.

1. The tablets must remain in your mouth for 30 minutes. After 30 minutes, swallow what does not dissolve.

Additional information regarding your medical abortion:

Some women wonder if they will see pregnancy tissue as they bleed. You may see a sac that is white or grayish and looks somewhat like a grape. You may see only blood clots. Typically, the embryo is not visible before about 8 ½ weeks of gestation.

Most women expel the pregnancy within 4 to 6 hours after placing the misoprostol. 90% of women expel the pregnancy within 24 hours. In rare cases, in may take a patient up to 14 days to completely expel the pregnancy. Your bleeding pattern will be unpredictable; you may bleed continually or you may also start bleeding, stop bleeding and then resume bleeding. Stay prepared with a pad or panty liner for your protection. You may experience the heaviest cramping during the expulsion process of the medical abortion. You may also pass blood clots ranging from the size of a quarter to the size of a small orange. Bleeding or spotting could last up to two or three weeks after using Misoprostol. Most women find that their pregnancy symptoms decrease within a couple of days.

Monitor your temperature for three (3) days after inserting the Misoprostol. Some patients may experience nausea, vomiting, diarrhea, fever, headaches and chills. You may want to have a heating pad or a hot water bottle on hand to help relieve cramping. Be sure to drink plenty of non-alcoholic, caffeine-free beverages (e.g. water, juice, sports drinks) to avoid dehydration. No alcohol or aspirin until your next visit as they may cause excessive bleeding. Please watch for any signs of complications. While it is rare to have an emergency, it is important that you make plans

ahead of time about how to call us and how you would get to our office or another medical facility if you need to.

EMERGENCY OR AFTER HOUR CALLS:If any of the following occur, please contact us immediately at (800) 545-2400 or (317) 955-2641(Please note: the return call will come from an unavailable, unknown, or private number)

1. If you are hemorrhaging, which means uncontrolled bleeding, seek emergency hospital care immediately. Take the MEDICATION GUIDE with you so that the provider in the emergency room will understand that you are having medical abortion with Mifeprex.

2. Please contact us if you are having severe, heavy bleeding. This means that you have soaked through two sanitary maxi-pads in an hour for two consecutive hours.

3. If you experience nausea, vomiting or diarrhea for more than 24 hours after placing the Misoprostol, this is NOT normal. In fact it could be life-threatening. Please call us.

Revised 08/05/19 4 of 4 M-3



EMERGENCY OR AFTER HOUR CALLS (continued):If any of the following occur, please contact us immediately at (800) 545-2400 or (317) 955-2641(Please note: the return call will come from an unavailable, unknown, or private number)

4. If you experience a fever of 100.4 or higher, please treat your fever with Tylenol. If the fever has not decreased in a 2 hour time period, please call us. Please note that it is not uncommon to experience chills along with your fever.

5. If you experience headaches, leg cramps, or abdominal pain treat with prescription pain medication or Ibuprofen/Aleve.

**If you have non-emergency questions or concerns, please call during normal business hours as non-emergency calls will not be returned. **

Your Third Clinic Visit It is very important that you return to CFW approximately 7 days following Mifeprex (Mifepristone. The

purpose of the third visit is to confirm the termination of your pregnancy by a VAGINAL ultrasound. You may be bleeding at your follow up visit, this is normal. If the medications have failed and there is a pregnancy within the uterus, you may be scheduled for a surgical abortion.

Please note that a urine pregnancy test following the medication abortion can be positive up for 6 weeks even though you are no longer pregnant.

Medical Abortion Follow-up Instructions: See page 4 of the Group Education Session packet.

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