KANSAS 24 HOUR INFORMED CONSENT

  • Bring this document with you to your appointment.
  • Please read and initial each section and sign your name at the bottom.
  • DO NOT mail to Comprehensive Health or Planned Parenthood.


To comply with Kansas Law effective July 1, 1998, you must receive this Informed Consent at least 24 hours prior to your procedure.

  1. Your abortion procedure will be performed by Orrin Moore, M.D. You will have the opportunity to meet with the doctor before your procedure.

  2. Estimated Gestation of Pregnancy: Until you have a sonogram to determine how far along the pregnancy is, the best way to estimate the gestation is by the date of your last normal menstrual period (LMP).
    If you believe your last normal menstrual period started: Then you are probably about:
    4 weeks ago 4 weeks pregnant
    5 weeks ago 5 weeks pregnant
    6 weeks ago 6 weeks pregnant
    7 weeks ago 7 weeks pregnant
    8 weeks ago 8 weeks pregnant
    9 weeks ago 9 weeks pregnant
    10 weeks ago 10 weeks pregnant
    11 weeks ago 11 weeks pregnant
    12 weeks ago 12 weeks pregnant
    13 weeks ago 13 weeks pregnant
    14 weeks ago 14 weeks pregnant
    15 weeks ago 15 weeks pregnant
    16 weeks ago 16 weeks pregnant
    17 weeks ago 17 weeks pregnant
    18 weeks ago 18 weeks pregnant
    19 weeks ago 19 weeks pregnant
    20 weeks ago 20 weeks pregnant
    21 weeks ago 21 weeks pregnant
    22 weeks ago 22 weeks pregnant

    The final determination will be made by the doctor upon ultrasound examination. If you are between 4 – 14 weeks, the common procedure is Vacuum Aspiration. Medication Abortion is available for pregnancy termination between 4 – 9 weeks. If you are between 15 – 22 weeks the most common procedure is Dilation and Evacuation. 

  3. Types of Abortion Procedures:

    First Trimester (4 – 13 wks LMP) Vacuum Aspiration – This abortion procedure begins with a local anesthetic given to numb the cervix. The cervix is then widened using dilators, which are tapered rods that gradually increase in size. The physician inserts a small tube (cannula), which is attached to an aspiration device. The device’s suction empties the contents of the uterus through the tube. The physician may check the walls of the uterus with a curette. The entire procedure takes less than 10 minutes. Sensations will vary, but they are mostly described as cramping or discomfort which generally subsides within a few minutes after the procedure is over. For more information on Early Surgical Abortion, refer the English or the Spanish version. 

    Early Non-Surgical/Medication Abortion (4 – 9 weeks LMP or up to 63 days) – While in the clinic, a drug, Mifepristone, is given to stop the development of the pregnancy. One to two days later, at home, a second drug (Misoprostol) is taken, causing the uterus to contract and expel the embryo and placenta. During this process cramping and bleeding will occur. For more information on Medical Abortion, click here .

    Second Trimester (14 – 22 weeks LMP) Dilation and Evacuation – During the initial appointment, the osmotic dilators are inserted into the patient’s cervix to begin the process of slow and gentle dilation of the cervix. The abortion procedure occurs several hours later, or in some cases one or two days later and involves removal of the pregnancy with forceps. A suction instrument is used to clean the uterus, and a curette is used to check the uterine walls. Patients are then monitored in recovery for at least two hours following the procedure. For more information on Mid-Trimester Abortion, refer the English or the Spanish version.

    Complications of Abortion – Possible complications include: blood clots accumulating in the uterus, requiring another suction procedure; infections, most of which are easily identified and treated if the woman carefully observes follow-up instructions; a tear in the cervix, which may be repaired with stitches; perforation of the wall of the uterus and/or other organs, which may heal themselves or may require surgical repair or, rarely, hysterectomy; an abortion that is not complete or that does not end the pregnancy may require the procedure to be repeated; excessive bleeding due to failure of the uterus to contract, which may require a blood transfusion; death. In the second trimester risks increase with every week of gestation.

  4. Risks with terminating a pregnancy vs. carrying a pregnancy to term – Health risks are low with either decision. There is approximately 1 death for every 167,000 women who have legal abortions and these rare deaths are usually of adverse reactions to anesthesia, heart attacks, or uncontrollable bleeding. The death rate for a woman carrying to term is about 10 times greater.

  5. Your blood type will be determined the day of your appointment. Approximately 15% of the population is Rh negative. All Rh-negative women will receive an injection of Rhogam to prevent problems with future pregnancies such as miscarriage, severe fetal anemia or permanent fetal damage. The cost of the Rhogam is $50 – $100 depending upon fetal age.

  6. Alternatives to abortion include parenting, foster care and adoption. Comprehensive Health of Planned Parenthood can give information for prenatal care, foster care and adoption to you.

    Medical assistance benefits may be available for prenatal care, childbirth, and neonatal care. Additional information will be available from the Kansas Department of Health and Environment. Community resources available to assist a women’s decision to carry a pregnancy to term include The Adoption Option, Catholic Charities, Child Placement Services, Division of Family Services and Family and Children Services of Kansas City. Outside the Kansas City area, check the yellow pages under Pregnancy Counseling.

  7. According to Kansas law effective July 1, 1998.

    A) ...“the father of the fetus is liable to assist in the support of her child even in instances where he has offered to pay for the abortion.”

    B) ...“the woman is free to withhold or withdraw her consent to the abortion at any time prior to the invasion of the uterus without affecting her right to future care or treatment and without the loss of any state or federally funded benefits to which she might otherwise be entitled.”

    C) “No person shall perform or induce an abortion when the fetus is viable unless such person is a physician and has a documented referral from another physician not legally or financially affiliated with the physician performing or inducing the abortion and both physicians determine that: 1) the abortion is necessary to preserve the life of the pregnant woman; or 2) a continuation of pregnancy will cause substantial and irreversible impairment of a major bodily function of the pregnant woman.” And “No person shall perform or induce a partial birth abortion on a viable fetus unless such person is a physician and has documented referral from another physician not legally financially affiliated with the physician performing or inducing the abortion and both physicians determine that: 1) the abortion is necessary to preserve the life of the pregnant woman; 2) a continuation of pregnancy will cause substantial and irreversible impairment of a major physical or mental function of the pregnant woman.” If the child is born alive, the attending physician has the legal obligation to take all reasonable steps necessary to maintain the life and health of the child.

  8. I received this information at least twenty-four (24) hours prior to my procedure.

 

 Please complete the following:

I received this information on Sunday, July 06, 2008  at 11:30 AM.

 

                                                                                                                                                                

Patient’s Signature                                                                                      Date

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PARENT/GUARDIAN NOTIFICATION

FOR PATIENTS UNDER THE AGE OF 18

1.                  I hereby swear under oath/or affirm, that I, ____________________________________, am the parent or

guardian of ____________________________________________, who was born on ___________________.
                                                           Daughter of Ward                                                                              Date of Birth

2.                  I have been informed that Orrin Moore, M.D. or Micheal Bates, M.D. intends to perform an abortion to terminate

the pregnancy of  ________________________________________ at her request.
                                                                 Daughter/Ward

3.         I am the person, under Kansas Law, entitled to notification.

____________________________________
Parent or Guardian Name, Please Print

____________________________________            _________________
Parent or Guardian Signature                                                    Date

 

State of __________________________)

(County) of _______________________)

Signed and sworn to (or affirmed) before me by

this ____________day of _____________, 200__.

(SEAL)

 

                        _________________________________________
                                                           Notary Public

 

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