1. What is the doctor's name who will be performing the abortion?
______________________________________
2. At which hospital does the doctor have privileges?
______________________________________
3. How is follow-up, or emergency care provided?
______________________________________
______________________________________
4. Has the doctor ever had any complaints or
malpractice suits against him?
__ Yes __ No
5. If yes, what were/are the complaint(s)?
______________________________________
______________________________________
______________________________________
6. What kind of procedure will be done?
______________________________________
7. What are the chances I will experience the following?
______ A life-threatening complication
______ Retained Products of Conception
______ Hemorrhage
______ Infection
______ Perforation of the Uterus
______ Sterility
______ Breast Cancer
______ Psychological & Emotional Trauma
______ Sexual Dysfunction
______ Suicidal Thoughts
______ Complications in future pregnancies
8. Describe the procedure in detail:
______________________________________
______________________________________
______________________________________
9. Will the abortion be painful for me?
__ Yes __ No
10. If yes, how much will it hurt?
__ Light __ Moderate __ Severe
11. How long will I be in pain?
______________________________________
12. Will my baby feel pain?
__ Yes __ No
13. What will the abortion cost?
______________________________________
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14. What does that fee cover?
______________________________________
______________________________________
______________________________________
15. Are there any additional fees?
__ Yes __ No
16. If yes, what are they?
______________________________________
______________________________________
______________________________________
17. Do you provide a blood test prior to the abortion to determine RH factor?
__ Yes __ No
18. Do you administer rhogam?
__ Yes __ No
19. Do you provide STD testing prior to the abortion?
__ Yes __ No
20. Do you provide counseling at least 24 hours before the abortion?
__ Yes __ No
21. If yes, what general information is provided?
______________________________________
______________________________________
______________________________________
22. Is it group or individual counseling?
______________________________________
23. Who will be providing the counseling?
______________________________________
24. If I change my mind before the abortion is performed, will I get my money back?
__ Yes __ No
25. Do you guarantee the procedure?
__ Yes __ No
Name of Clinic: ______________ Date: ______
Compare the answers you gather above to the information on
A Woman's Health & Safety Checklist, before risking your
emotional, and physical health. Keep this information in a safe
place. It provides evidence of your care. Some effects from abortion
may not surface for many years.
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