1. I have read the attached MEDICATION GUIDE for using Mifeprex and misoprostol to end mypregnancy.
2. I discussed the information with my health care provider (provider).
3. My provider answered all my questions and told me about the risks and benefits of using Mifeprex andmisoprostol to end my pregnancy.
4. I believe I am no more than 49 days (7 weeks) pregnant.
5. I understand that I will take Mifeprex in my provider’s office (Day 1).
6. I understand that I will take misoprostol in my provider’s office two days after I take Mifeprex (Day 3).
7. My provider gave me advice on what to do if I develop heavy bleeding or need emergency care due tothe treatment.
8. Bleeding and cramping do not mean that my pregnancy has ended. Therefore, I must return to myprovider’s office in about 2 weeks (about Day 14) after I take Mifeprex to be sure that my pregnancy hasended and that I am well.
9. I know that, in some cases, the treatment will not work. This happens in about 5 to 8 women out of 100who use this treatment.
10. I understand that if my pregnancy continues after any part of the treatment, there is a chance thatthere may be birth defects. If my pregnancy continues after treatment with Mifeprex and misoprostol, Iwill talk with my provider about my choices, which may include a surgical procedure to end my pregnancy.
11. I understand that if the medicines I take do not end my pregnancy and I decide to have a surgicalprocedure to end my pregnancy, or if I need a surgical procedure to stop bleeding, my provider will do theprocedure or refer me to another provider who will. I have that provider’s name, address and phonenumber.
12. I have my provider's name, address and phone number and know that I can call if I have anyquestions or concerns.
13. I have decided to take Mifeprex and misoprostol to end my pregnancy and will follow my provider’sadvice about when to take each drug and what to do in an emergency.
14. I will do the following: contact my provider right away if in the days after treatment I have a fever of 100.4°F or higherthat lasts for more than 4 hours or severe abdominal pain.
contact my provider right away if I have heavy bleeding (soaking through two thick full-sizesanitary pads per hour for two consecutive hours).
take the MEDICATION GUIDE with me when I visit an emergency room or a provider who did notgive me Mifeprex, so that they will understand that I am having a medical abortion with Mifeprex.
return to my provider’s office in 2 days (Day 3) to check if my pregnancy has ended. My providerwill give me misoprostol if I am still pregnant.
return to my provider’s office about 14 days after beginning treatment to be sure that mypregnancy has ended and that I am well Patient Signature: ___________________________________________ Patient Name (print): ________________________________________ Date: _____________________________________________________ The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered allher questions. I have given her the MEDICATION GUIDE for mifepristone.
Provider’s Signature: ________________________________________ Name of Provider (print): ______________________________________ Date: _____________________________________________________ After the patient and the provider sign this PATIENT AGREEMENT, give 1 copy to the patient before sheleaves the office and put 1 copy in her medical record. Give a copy of the MEDICATION GUIDE to thepatient.

Source: http://www.teachtraining.org/officepractice/DancoPatientAgreement.pdf


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