Patient Forms: Abortion Pill

SAVE TIME! FILL OUT THESE FORMS BEFORE YOUR APPOINTMENT.

Follow the instructions below on what to print out, read, and watch before you come in for your medical abortion appointment.

• HIPAA Notice: Read our notice of health information privacy practices.
• Medication Abortion Informational Video: Watch this informational video before your appointment. You will sign a statement when you come in stating you reviewed this video.
• Patient Forms: Print the following forms and bring them with you to your appointment:

  • Section B Patient Information - please fill this out completely.

  • Section D Informed Consent - please read this over completely. Make a note of any questions you might have to review with your counselor.

  • Section 1 Medical History - please fill this out completely.

  • Financial Policy - please read, sign and date top portion and, if you have medical insurance, the middle section. If you are using financial assistance, also sign and date the bottom portion.

  • Homecare Packet - please read through. Print out if you would like to keep a hardcopy at home.

By reading and completing this paperwork before your appointment, you will significantly reduce your time in the clinic. Have any questions you have ready for the patient advocate when you come in.

If you have questions, please don’t hesitate to call us.

1-800-447-7354