CLINIC FOR WOMEN

REQUIRED COMPONENTS FOR ABORTION CONSENT DOCUMENTATION

Pursuant to IC 16-34-2-1.1

(1)        I hereby consent to an abortion.

(2)        At least eighteen (18) hours before the abortion the physician who is to perform the abortion, the referring physician or a physician assistant, an advanced practice nurse, or a midwife to whom the responsibility has been delegated by the physician who is to perform the abortion or the referring physician has orally informed me of the following:

(A) The name of the physician performing the abortion.

(B) The nature of the proposed procedure or treatment.

(C) The risks of and alternatives to the procedure or treatment.

(D) The probably gestational age of the fetus, including an offer to provide:

                        (i)         A picture or drawing of a fetus;

                        (ii)        The dimensions of a fetus; and

                        (iii)       Relevant information on the potential survival of an unborn fetus

(E) The medical risks associated with carrying the fetus to term.

(F) The availability of fetal ultrasound imaging and auscultation of fetal heart tone services to enable me to view the image and heart he heartbeat of the fetus and how to obtain access to these services.

(G) That before the abortion is performed, that I may, upon my request, view the fetal ultrasound imaging and hears the auscultation of the fetal heart tone if the fetal heart tone is audible.

(3)        At least eighteen (18) hours before the abortion, I was orally informed of the following:

(A) That medical assistance benefits may be available for prenatal care, childbirth, and neonatal care from the county office of family and children.

(B) That the father of the unborn fetus is legally required to assist in the support of the child.

(C) That adoption alternatives are available and that adoptive parents may legally pay the costs of prenatal care, childbirth, and neonatal care.

I certify that the above information was received by me at least eighteen (18) hours prior to the date and hour scheduled for my abortion. I fully understand the full nature and extent of this consent and I,     therefore, affix my name on this __________ day of _____________, 20____, at

________________________________, Indiana at _____________ am/pm.

_________________________________________

(Signature of Patient)

_________________________________________

(Printed Name of Patient)

_________________________________________

(Signature of Physician/Physician's Assistant! Advanced Practice Nurse/Midwife)

Abortion Consent.doc