Abortion Disclosure Form

Patient Rights

WARNING!

DO NOT ALLOW ANYONE TO PERFORM AN ABORTION ON YOU,
WHO REFUSES TO COMPLETE AND SIGN THIS DOCUMENT.

Also, under no circumstances should you allow anyone to take this form away from you,
INCLUDING the doctor who is performing your abortion or any member of the clinic or hospital staff.
This document may be photocopied if necessary, but in order to protect your legal rights you should
keep it in your possession at all times.

Call and make your appointment to schedule 
your pregnancy confirmation and rights card.
 

PHYSICIAN INFORMATION

I hereby certify that I am a physician licensed to operate in the state of:

____________________________________________________________

 I also certify that I have a current and fully-paid insurance policy [see below] that will protect
you in the event of either medical malpractice, personal injury or wrongful death. Furthermore,
I have no outstanding or unpaid claims or judgment against me for either medical malpractice,
personal injury or wrongful death.

______________

DATE

___________________________________________MD

SIGNED

 THE FOLLOWING INFORMATION MUST BE COMPLETED BY
THE PHYSICIAN SIGNING ABOVE.

NAME OF INSURANCE COMPANY:_________________________________________

________________________________________________________________________

CITY:____________________________ STATE:________________________________

POLICY NUMBER:________________________________________________________

EXPIRATION DATE:________________________________________________________