Guidelines:
PATIENT AGREEMENT
(Medical termination
of pregnancy)
1. I have read the attached Patient Information Leaflet
for using Mifepristone and prostaglandin analogue to end
my pregnancy.
2. I discussed the information with
my health care provider (_ _ _ _ _ _ _ _ _ _ _).
3. My provider answered all my questions and told me about
the risks and benefits of using Mifepristone and prostaglandin
analogue to end my pregnancy.
4. I believe I am no
more than 56 days (8 weeks) pregnant.
5. I understand
that I will take prostaglandin analogue in my provider’s
office or at home two days after I take Mifepristone (Day
3).
6. My provider gave me advice on what to do if
I develop heavy bleeding or need emergency care due to the
treatment.
7. Bleeding and cramping do not mean that
my pregnancy has ended. Therefore, I must return to my provider’s
office in about 2 weeks (about day 14) after I take Mifepristone
to be sure that my pregnancy has ended and that I am well.
8. I know that, in some cases, the treatment will not
work. This happens in about 5 to 6 women out of 100 who
use this treatment.
9. I understand that if my pregnancy
continues after any part of the treatment, there is a chance
that there may be birth defects if my pregnancy continues
after treatment with Mifepristone and prostaglandin analogue,
I will talk with my provider about my choice, which may
include a surgical procedure to end my pregnancy.
10. 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 surgical procedure to
stop bleeding, my provider will do the procedure or refer
me to another provider who will. I have the provider’s name,
address and phone number.
11. I have my provider’s
name, address and phone number and know that I can call
if I have any questions or concerns,
12. I have decided
to take Mifepristone and prostaglandin analogue to end my
pregnancy and will follow my provider’s advice about when
to take each drug and what to do in an emergency.
13. I will do the following:
- If my pregnancy is
not ended within 2 days (Day 3) after I have taken Mifepristone
I will take prostaglandin analogue.
- I will return
to my provider’s office about 14 Days after beginning the
treatment to be sure that my pregnancy has ended and that
I am well.
Patient Signature____________________
Patient
Name (print) __________________
Date______________________
The patient signed the PATIENT AGREEMENT in my presence
after I counselled her and answered all her questions. I
have given her the Patient Information Leaflet.
Provider’s Signature____________________
Name of
provider (Print)________________________
Date_____________________
(After the patient and provider sign this PATIENT
AGREEMENT, give 1 copy to the patient before she leaves
the office and put 1 copy in her medical record. Give a
copy of the Patient Information Leaflet to the patient.)
click here to download[PDF]
