I, {patientsName}, request and consent to the administration of Mifepristone and misoprostol with the intent to abort my pregnancy. This medication will be provided to me by Southwestern Women’s Options.

I understand a medical abortion is one that is brought about by taking medications which cause the body to abort or expel the pregnancy rather than the alternative of surgical abortion which ends the pregnancy by emptying the uterus with the use of special instruments. Two medications, mifepristone and misoprostol, will be given over the course of several days; together they will induce an abortion. Both mifepristone and misoprostol have been approved by the FDA for use in early abortion procedures. I understand that the protocol used in my treatment may differ from the FDA labeling, however only when the change has been proven beneficial. The protocol adopted by the Clinic for the combined use of mifepristone and misoprostol in early abortion procedures has been studied and reported in medical literature and scientific evidence indicates that it is safe and effective. The overall success rate for this process is approximately 99%.

I have fully and completely disclosed my medical history, including allergies, medical conditions, prior medications, over the counter or other drugs taken, and reactions I have had to anesthetics, medicines, or drugs. I consent to treatment based upon my disclosure and/or upon findings from examinations.

I fully understand that the purpose of the treatment is to terminate this pregnancy, and I affirm this to be my personal choice in light of the alternative of continuing the pregnancy to term. No one has coerced or compelled me to make this decision.

I affirm that no guarantee or assurance has been made to me as to the results that may be obtained. I understand that there is approximately a 1%-5% possibility that the medications may not be sufficient to abort my pregnancy. I understand that a surgical abortion or a D&C may be required. Further, I agree to a surgical abortion or D&C when recommended by my provider. I also understand that I may request a surgical abortion or D&C at any time during my treatment. I understand that once treatment has begun (taking the mifepristone tablet), my pregnancy must be aborted, either surgically or medically due to the high risk of severe fetal abnormalities caused by the use of mifepristone and misoprostol.

I understand that neither mifepristone nor misoprostol is known to harm future pregnancies.

I understand that any prescribed medication is to be used only by the person for whom it has been prescribed, and must be kept out of the reach of children or persons of limited capacity to read or understand.

I understand that the complications associated with early pregnancy termination are generally much less severe and less frequent than with childbirth. Nonetheless, I realize, as is true of childbirth and any kind of medical process, there are inherent risks of minor and major complications and death, which occur without the fault of the physician.

Pregnancy, birth and abortion all have risks. Abortion is safer than carrying a pregnancy to term. The risks and possible complications of the abortion procedure are rare. In a small number of cases these may occur:

• Medication Side Effects: Medications may cause rare side effects. Most women have no side effects. The most commonly occurring side effects of misoprostol may include nausea, vomiting, diarrhea and dizziness. Most of the side effects will last only a few days with the exception of light bleeding which could last two to three weeks. Although most side effects are usually mild and manageable, in a small number of cases, severe reactions or complications requiring additional measures and treatment may occur. Also some women may experience unknown or unforeseen reactions to a medication. The most common side effect of mifepristone is bleeding.
• Hemorrhage: Although moderate to heavy bleeding is very normal following the administration of the mifepristone and the misoprostol, excessive bleeding is not. Excessive bleeding may require a surgical or D&C procedure, or hospitalization for observation and treatment. There have been instances of hemorrhage occurring as long as 4 to 6 weeks after taking of the Mifepristone. In very rare cases, a blood transfusion may be necessary.
• Infection: Infections usually respond to antibiotics, but in a few cases, hospitalization is necessary. There is a rare but fatal infection that has occurred in patients using Mifepristone for abortion. Infection can occur when pregnancy tissue remains in the uterus.
• Failure to Terminate Pregnancy/ Retained Products of Conception: In a small number of cases, the abortion process fails to end the pregnancy or a small amount of pregnancy tissue remains in the uterus. It is this possibility, among others, that makes a post-abortion examination essential. In such a case, a surgical abortion or D&C procedure must be recommended, since the use of the medications are shown to affect normal development of pregnancy and cause birth defects.
• Tubal Pregnancy: A tubal pregnancy occurs when the fertilized egg implants in the fallopian tube or somewhere instead of the uterus. If this condition is unchecked, and the fetus develops in the tube, it would grow large enough to burst the tube. Although the chances of tubal pregnancy are small, the risk of death from a ruptured tubal pregnancy is very great. For this reason, all tubal pregnancies should be monitored by your own physician or in a hospital setting; the medical or surgical abortion procedure provided at The Clinic cannot terminate a tubal pregnancy. I understand that this is a preexisting medical condition for which the Clinic assumes no medical or financial responsibility.
• Hysterectomy: I understand that as a result of certain conditions or some complications (such as excessive bleeding or severe infection) a hysterectomy may be necessary.
• Sterility: In extremely rare cases, a severe complication may result in a loss or decline of reproductive capabilities.
• Emotional distress: Individual women cope differently with pregnancy, birth and abortion; most patients go through the process with minimal emotional effects, but in some cases professional help is required. I release the attending physicians and staff from any liability or responsibility for any condition that may result from this procedure, including but not limited to short range or long term psychological effects resulting from my decision to have this abortion.

I understand that my provider and/or counselor will answer any questions I have, and I will ask such questions during my telemedicine appointment. If I have questions or complications after my appointment, I agree to call the Clinic at (505) 242-7512 or (800) 777-7630 immediately. I also agree to receive a follow-up phone call from the Clinic one week after the administration of the mifepristone, and to take a home pregnancy test one month after administration of the mifepristone, in order to rule out a continued pregnancy or the existence of other problems. I understand that by choosing a medical abortion, additional follow-up including the possibility of an in-person visit may be required.

I UNDERSTAND THAT, WHEN POSSIBLE, I MAY BE TREATED FOR ANY RESULTING COMPLICATIONS AT CURTIS BOYD M.D. P.C. AT NO CHARGE TO ME; HOWEVER, SHOULD HOSPITALIZATION BE NECESSARY, I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY CHARGES.

I understand that the medical practice of my physician is to be judged according to those standards reasonably acceptable to other physicians practicing in other similar facilities in the United States. If I am dissatisfied with my care for any reason then I should try to resolve my complaint with the Clinic Director.