Patient Name

Today's Date

Home Address

City State Zip Code

Work Address

City State Zip Code

Home Phone Work Phone

Cell Phone

Federal privacy rules require that you tell us how to contact you with information, lab results, appointment changes, and other information that is crucial to your care with Family Planning Associates Medical Group.

Call my home numberCall my work numberCall my cell number

If you have to leave a message, say...

I understand that staff may periodically need to contact me about test results or other information about my care with Family Planning Associates. I have made my preferences known about how to contact me.

I also understand that critical situations may arise that require Family Planning Associates to make contact with me quickly. If unable to do so, I understand that Family Planning Associates may send certified mail to my home address as a way to make direct contact with me. By signing below I agree to Family Planning Associates' contact procedures.

Patient Signature Witness

Parent or Guardian Date and Time

Social Security #

In case of Emergency Please Notify:

Name

Address

Phone

Please check all that apply.

The best way to telephone me is:

"Family Planning Associates called""your doctor's office called""Casey called" (this is our 'code' for a call from this clinic)

Never call me

Please list any other way to reach you

How did you hear about Family Planning Associates?

Yellow PagesInternetReferred by Dr.

Referred by a friendSaw ad in

Radio AdBeen here beforeOther

Date of Birth

Patient Information

Patient contact information rev 2014-0422

Patient Name

Age

State of Arizona Required Information

How many years of education have you had, including grade school, college, graduate or professional school?

Are you a resident of Arizona? Yes No

If yes, in what county do you live?

If you are not a resident of Arizona, are you a resident of the United States? Yes No

Are you of Hispanic origin? Yes No

Please indicate your race. Check all that apply:

White Asian

American Indian

Black or African American

Native Hawaiian or other Pacific Islander

Other

Are you married? Yes No

How many times have you been pregnant? Do not include this pregnancy.

How many births have you had?

How many abortions have you had? Do not include the abortion you are having today

How many miscarriages have you had?

Arizona law requires that we collect and report the following information. This information is kept entirely confidential and your name will not be included when it is reported to the state.

PATIENTS DO NOT WRITE BELOW THIS LINE

Gestational age

Indicationelective medical mother medical fetus anencephaly medical fetus spina bifida medical fetus other

Proceduresuction D&C D&E MAB

Complication?

Pre-existing medical problem that would complicate pregnancy?

Date of Abortion Physician

State Required Information rev 2014-0303

Medical History

Patient Name DateAge

How many times have you been pregnant, including this time?

# of live births # of miscarriages # of abortions # of c-sections

Have you ever had an ectopic or tubal pregnancy? Yes No

When did your last menstrual period start? Was it a normal period? Yes No

Have you had any bleeding since your last period? Yes No

Have you ever had complications after childbirth, abortion, or miscarriage, including excessive bleeding?Yes No explain

Please list any operations that you have had including c-sections, D&C's, and procedures on your cervix:

Are you allergic to any medications? Yes No If yes, please list the medications and type of reaction below:

Are you currently on any medications? If yes, please list them below:Yes No

Do you use any recreational drugs such as cocaine, heroin, methamphetamine, etc.? Yes No If yes, which drug(s)? When did you last use?

What birth control methods have you tried?

Do you smoke? Yes No

Please check if you have, or have had any of the following?

Reaction to iodine

AnemiaAsthma

Bleeding tendencies

Blood transfusionsBlood clots in your legs or lungs

Diabetes

Reaction to novacaine or other anesthetics

Heart disease

Hepatitis

Breast lumps or tumors

Heart murmur

HIV/AIDS

High blood pressure

Kidney disease

Migraine headaches

Mitral valve prolapse

Psychiatric illness

Seizures or epilepsy

Pelvic inflammatory disease (PID)

Chlamydia

Gonorrhea

Genital warts

Herpes

Syphilis

Other

I certify that the information I have provided is true, correct, and complete.

Are you currently breastfeeding? Yes No

Patient signature Date

Are you allergic to latex? Yes No

Please indicate below how your previous pregnances ended.

History rev 2014-0921

Have you ever had an operation to burn or freeze the lining of your uterus to stop your periods? Yes No

ROS

History reviewed with patientPhysician signature Date

Counseling Information

Patient Name Date

You have made the choice to end your pregnancy today. This may have been a difficult decision for you. You will meet with a counselor who will help you with any questions, concerns or conflicts you might have. Answering the following questions can help us with your particular situation. Of course, all information is confidential.

Have you talked to anyone about your decision to have an abortion? If so, who?

Physician Counselor Family Friend Partner Other

1.

2. Who is supportive of your decision?

Family Friend Partner Nobody Other

Do you feel that anyone has pressured you into having an abortion?3.

Yes No If yes, please explain below (who, how, why?)

4. Are you sure you want to have an abortion?

Yes No

5. Is there anything else you think we should know that would assist us in your care?

No Please explain

6. What method of birth control would you like to try today?

Counselor's comments

Counselor's signature

Physician's Comments

Physician's signatureCounselng Information rev 2013-1118

Yes

In accordance with the Federal Privacy Law (HIPPA), Family Planning Associates keeps medical information and records confidential and will only use them for patient treatment, health care operations, and billing purposes.

Treatment:Our physicians, clinicians, and staff will use your medical information to give you the best possible care.

Health Care Operation:Family Planning Associates will use this information for appropriate follow-up care, patient notification, statistical and regulatory requirements, and internal quality assurance programs.

Billing Purposes:Family Planning Associates will use your medical information to bill the appropriate third party or parties for your care.

Disclosure of Information with Extenuating Circumstances

Health information will be given to family members in case of an emergency or under other circumstances with proper authorization and documentation.

Health information may be given to other physicians or institutions under emergency situations.

Information may be given to proper authorities when neglect or abuse is alleged or suspected.

Information may be provided to courts or other agencies when a subpoena is given to this office.

1.

2.

3.

4.

I understand that if I have any questions I can speak to a Family Planning Associates Privacy Officer.

I understand and agree to the above Privacy Policy.

Patient Signature Witness

Patient name - Printed Date and Time

I agree to allow Family Planning Associates to contact my referring physician for the purpose of continuity of care.

Yes No N/A Initials

Patient Privacy Notice

Patient Privacy notice rev 2014-0422

Statement of Patient Rights

Patient Rights

All women having an abortion in Arizona have the following rights:

1. To refuse treatment or withdraw consent for treatment;

2. To have medical records kept con�dential;

3. To be informed of:

a. Billing procedures and �nancial liability before abortion services are provided;

b. Proposed medical or surgical procedures, associated risks, possible complications and alternatives;

c. Counseling services that are provided in the physical facilities; and

d. If an ultrasound is performed, the right to review the ultrasound results with a physician, a physician assistant, a nurse practitioner, or a registered nurse before the abortion procedure.

I acknowledge that I have read and understand my rights as a patient as indicated above.

_______________________________________ Signature of patient

_______________________________________ Date

Arizona law prohibits a physician from providing an abortion based on the sex or race of the fetus or the race of either parent. It also prohibits a physician from accepting payment for an abortion sought for those reasons. Because of this law, we are asking our patients to sign a statement affirming that they are not seeking an abortion because of the sex or race of the fetus, the race of the father, or their own race.

Certification That Abortion Is Not Being Performed On The Basis of Sex or Race

I, ________________________________ (patient name), certify that my decision to have an abortion is not based on the sex or race of the fetus, the race of the father, or my own race. I further certify that the abortion is not being financed because of the sex or race of the fetus.

___________________________________________(Patient Signature)

___________________________________________(Date)

Abortion Based on Gender or Race

Race or Gender Certifcation