ULTRASOUND EXAMS The ultrasound exams that we perform here are limited to the estimation of the gestational age (size) of an INTRAUTERINE PREGNANCY. It is understood that there is a range of uncertainty of about ± 4-10 days due to the limited capabilities of the method and the machine. We only perform ultrasounds on patients who plan to terminate their pregnancy, and the ultrasounds are for our own internal purposes. They will NOT detect any abnormalities of the pregnancy, including fetal anomalies or ectopic pregnancies. We are unable to provide any information regarding the health, gender or well-being of your pregnancy. While the pictures from every exam will be reviewed by one of our doctors at the end of the day, we are not authorized to release any official report or copies of the ultrasound pictures. We do not accept any liability resulting from any assumptions or conclusions that you may make as a result of this exam. Ultrasounds photocopies will not be provided to patients prior to an abortion being performed. You may pay for a copy as part of your medical records AFTER your abortion at.60 cents per page. INCLUDED in the price of your abortion is a $100.00 charge for the ultrasound examination. If for ANY reason you DO NOT have an abortion today, we will keep this $100.00 for services rendered. These reasons could include: you are NOT pregnant, you change your mind about having an abortion, if you are too early pregnant to have an abortion (less than 6 weeks), or if you are too far along to have an abortion in our office (>18.6 weeks). By signing below, I agree that I have read and understood this information. At this point, it is my intention to terminate my pregnancy. Patient s Printed Name: Patient s Signature: Office Staff Signature: Date:
IMPORTANT PATIENT INFORMATION As of this date (since 2001), there have been 8 deaths reported in women who have used Mifreprex (RU-486) pill for a medical abortion. One of the deaths was due to an undiagnosed ectopic (tubal) pregnancy and had nothing to do with the medical abortion procedure. We have already taken steps in an attempt to exclude an ectopic pregnancy for you. The remaining 7 deaths were due to a very rare infection, some caused by a bacterium called Clostridium sordellii. One of these deaths occurred in Canada, one in an unannounced location, and four in California. Clostridium sordellii is a common soil and enteric bacterium that has presented in a very small number of obstetric and gynecologic cases, including following childbirth (vaginal delivery and Cesarean section), medical abortion, and in other gynecologic and non-gynecologic conditions. Most of the reported cases of Clostridium sordellii infection, regardless of location or procedure (abortion, miscarriage, vaginal delivery, Cesarean Section, gynecologic surgery or knee surgery) have been fatal, indicating that this organism is very virulent and difficult to diagnose and treat. As Stated above, this is a very rare infection. There have been only 6 cases reported in over 540,000 medical abortions (1.2 per 100,000). This death rate is very similar to the rate for spontaneous miscarriage, and 1/11th the death rate for childbirth which is about 13 per 100,000. That s right; you are 11 TIMES MORE likely to die if you stay pregnant. This information is NOT intended to frighten you or to turn you away from the abortion pill. However, the death rate for early surgical abortions (less than 10 weeks) is only one per million. Early surgical abortion takes less than 5 minutes and compared to the abortion pill is 10 times safer and less painful. We will be giving you an antibiotic pill to take in the laboratory to reduce the risk of infection even further. We STRONGLY recommend using Maxi-Pads rather than tampons for both medical and surgical abortions. If you must use tampons for work, you have to change them every 3-4 hours and wear pads whenever you can. It is also important NOT to have sex for two weeks. The important information for you to know is that that you should expect significant pain and bleeding for only the ONE to TWO days after insertion of the vaginal pills. If you feel that you are getting worse rather than better, you must call us and come in to the office for an examination. It is also VERY important for you to return for a check-up visit 1-2 weeks after the first pill and to follow your doctor s instructions completely. Signature of Patient Date Signature of Office Staff Date
Patient s Name: DOB: CONSENT FOR AN EARLY MEDICAL ABORTION Place your initials after each statement to indicate that you have read, understand, and agree with the statement. I understand that my three options regarding this pregnancy are parenthood, adoption and abortion. The alternative to medical abortion is surgical abortion either now or later in my pregnancy. The term medical abortion is used for an abortion that is done using drugs or medications. A surgical abortion is one in which instruments are used to empty the uterus or womb. I know that I should not begin a medical abortion unless I am sure that I want to end my pregnancy, and I am willing to have a surgical abortion if the medical abortion fails (about 2 in every 100 patients). I understand that a medical abortion must be done within 9.6 weeks of pregnancy. A physical exam and/or a trans-vaginal ultrasound examination will be done to make sure of the size of my pregnancy. I understand that I must show proof of living in Las Vegas (or a surrounding area like Henderson, Green Valley, Boulder City or Summerlin) in order to be considered a candidate for the abortion pill process. This proof may be a Nevada driver s license, a current paycheck stub, car registration, phone bill or other documentation with my name on it. If I cannot show acceptable documentation to A-Z Women s Center, I may reschedule my appointment or choose to have the surgical procedure today instead. To be considered a candidate for the abortion pill, I understand that I must be 18 years or older (and show proof of age) and have two consecutive days off of work or school. It is okay for you to work today after taking the first pill (Mifeprex) here in our office. On, the above mentioned patient stated that her days off would be and Tech: Patient s 1 st check-up visit: Patient s 2 nd check-up visit:
The medical abortion process requires two different medications used together. The first is Mifeprex which blocks the action of progesterone, a hormone needed to continue a pregnancy. This drug was approved by the FDA for this use in September 2000 and has been used widely in other countries for this purpose (it is sometimes referred to as the French Abortion Pill or RU-486). I will be given a 200-mg dose rather than the FDA approved 600-mg dose because newer research shows this is just as effective. The second drug is Misoprostol (Cytotec). Misoprostol causes the uterus to cramp heavily, which will expel the pregnancy. Before I am given the medications I will have a blood test done to check me for anemia and to check my RH type. If I am RH Negative and over 7.6 weeks pregnant, I will get a shot of Rhogam. Please advise us if you have already RECENTLY received this injection somewhere else. I will be given the Mifeprex tablet to swallow before I leave A-Z Women s Center. I understand that this medicine can cause some nausea, and an upset stomach. We do not recommend taking this pill on an empty stomach. If you have not eaten yet today PLEASE RE-SCHEDULE YOUR APPOINTMENT UNTIL YOU HAVE FOOD IN YOUR STOMACH. I understand that if I vomit within the first 30 minutes of taking the Mifeprex, the effectiveness of the Mifeprex is significantly decreased. You can choose to take your chances that it will work or you can purchase another pill for $100.00. I understand that I will be given a prescription for 4 tablets of Misoprostol. You will take this prescription along with your pain pill prescription to your local pharmacy to get filled on your way home today. Keep in mind that Walgreens and CVS are the two most expensive pharmacies in town. For cheaper costs, please use Target, Walmart, K-mart or Costco s pharmacies. The cost for this medication should be $8.00 - $10.00 from the cheaper pharmacies mentioned above. I understand that I will insert all 4 tablets into my vagina NO SOONER than 12 hours after I swallow the Mifeprex tablet in the office, but before 36 hours have passed. Lie down on your bed or flat surface and insert all 4 tablets into the vagina. I understand that a second dose of the Misoprostol may be needed if the first dosage does not completely work. Vaginal administration of this medication has been shown to be more effective, especially for pregnancies less than 9.6 weeks in size.
I understand that I will be given a prescription for pain medication. Some patients prefer to start out taking over the counter medication (Advil, Motrin or Ibuprofen) and if you need a stronger medication take the prescription you received from the doctor to the pharmacy. You can do this at the time you fill your Misoprostol prescription or you can wait to see if you will need it. The cost for this medication should be $8.00 - $10.00 at K- mart, Target, Walmart, and Costco. I know that I can reach the on-call provider at any time if I experience any emergency problems at (702) 892-0660 after normal business hours and follow the recorded message prompts to get the on-call physician. I understand that one to five hours after the Misoprostol is inserted into my vagina, I will experience heavy cramping and bleeding. The cramping can be very strong and painful for several hours, but not usually for more than 18-24 hours. The bleeding can be quite heavy and there may be large clots for several hours. Some patients have reported passing clots the size of their hand. Understand that you may also see some pregnancy tissue (usually white or gray in color). If the heavy bleeding lasts for more than 12 hours, or if I soak (front to back and side to side) more than two maxi pads each hour for two hours in a row, I know that I should call the office at (702) 892-0660. If you call our office after 5:00 pm, please follow the recorded message prompts to get the on-call physician. I know that I MUST return for my one-week check-up to be sure that the abortion is complete. I know that at this visit a trans-vaginal ultrasound will be performed by the physician. If the abortion has not been completed, I will have the option of taking another dose of the Misoprostol or having a vacuum aspiration (a surgical suction procedure to empty the uterus) to complete the abortion. I understand that if I do not return for my one-week check-up, I will receive a phone call at my home or cell number to re-schedule. I also understand that if I do not return for the re-scheduled appointment, the office will discharge me from their care for future medical abortion services. I agree not to hold them responsible for anything that may happen to the pregnancy, or myself as a result of me not returning for follow-up care. This includes, but is not limited to, low birth weight, severe birth defects, or even death of the pregnancy. I understand that it is important that the abortion be completed because the 4 Misoprostol tablets can cause serious birth defects.
I understand that this is a two-step process. One medication typically does not successfully terminate the pregnancy. You NEED to get the second medication (Misoprostol) from the pharmacy to ensure success. I have read this form and have had time to think about it. I understand that I will have a consultation with the physician today. At that time I will have the opportunity to ask any questions before beginning the medical abortion process. In the event of an unexpected complication during the medical abortion procedure, I request and authorize Dr. William Ramos and/or Dr. Kernes to do whatever is necessary to protect my health and welfare. I understand that once I take the abortion pill, Mifeprex, I MUST complete the medical abortion process by inserting the 4 Misoprostol pills. I have been advised that the medication will detach the pregnancy from the inside of the uterus. The pregnancy MAY not be viable should I decide to change my mind and not complete the medical abortion process. I hereby consent for Dr. Ramos and/or Dr. Kernes to give me the medication Mifeprex ( The Abortion Pill ) to swallow in the office today. I also acknowledge that I will be receiving a prescription for 4 Misoprostol (Cytotec) pills to be inserted vaginally to induce an early medical abortion. Signature of Patient: Print Patient s Name: Today s Date: Office Staff s Signature: Today s Date: Physician Signature:
Please leave this form blank if you do not want or do not need birth control of any type. Patient s Name: Date: Birth Control Questionnaire We strongly encourage all patients to start on a form of birth control (contraception) to help avoid future unplanned pregnancies. This questionnaire will assist us to suggest the methods that we feel are best for you. If you do not want contraception, stop now. What method do you prefer? Condoms Pills Patch Vaginal Ring Injection Diaphragm IUD Tubal Ligation or Vasectomy (Permanent Sterilization) If you chose pills, the Ortho Evra patch, the Nuva Ring or the Depo-Provera injection, continue the questionnaire (Be honest, these questions are important). 1. How old are you? 2. Do you smoke cigarettes? a. How much per day? 3. How much do you weigh? 4. What forms of contraception have you used in the past? 5. Did you have any problems with those methods? 6. Have you ever gotten pregnant while using contraception? a. With what method? 7. Have you ever had: High Blood Pressure Breast Tumor Osteoporosis Blood Clot in Legs Severe Acne PMS Excessive Facial Hair 8. Will you have to hide your birth control from your partner or parents?
Patients: Please leave this form blank. The nurse will do this with you in the laboratory Patient s Name: DOB: MEDICAL ABORTION CHECKLIST YES NO N/A Did the patient read the MIFEPREX: Early Option Pill Brochure? Was the patient advised of her pregnancy options? Was the patient notified that she needs time off work? Today thru 48 hours later in order for the Misoprostol pills to complete the process? Did the patient initial and sign the consent form? Is the pregnancy less than 9.6 weeks by ultrasound? Did you explain the need for all follow-up visits? Did you explain our on-call system? Does the patient have an IUD in place? Does the patient have any known allergies to Mifeprex/prostaglandins? Has an ectopic pregnancy been ruled out? Does the patient have a history of chronic adrenal failure? Does the patient have a history of hemorrhagic disorders? Does the patient have a history of anticoagulant therapy? RH STATUS: (CIRCLE ONE) POS NEG ------- Rhogam given: (IF INDICATED) Hemoglobin level: Instructed Misoprostol 800 mcg to be inserted after 12-36 hours, vaginally Was a Rx for pain & Misoprostol written? Contraception Plan: OC Rx written?