Patient Intake Forms

Select your appointment type:*

Abortion Care

Gynecology

Patient's Full Name*

First Last

Preferred Name (Optional)

(If you would like to be called something other than the official name on your medical records, please enter it here.)

Pronunciation (Optional)

(If you would like to help us with the pronunciation of your name, please enter it here.)

Date of Birth*

Age*

Please enter a number from 0 to 100.

Minor Patient Acknowledgment*

Minors seeking abortions in Virginia must have a notarized form from a parent or guardian signing off on their abortion. By checking this box I acknowledge that I will discuss this with a Patient Educator and bring a notarized form or have the notary done in-person at FCHC.

Mobile Phone number*

May we leave a message?*

Yes

No

Home Phone number

Valid Email Address*

Preferred method of contact:*

Email

Phone

Home Address*

Street Address Address Line 2 City State ZIP Code

Check Travel

Check here if you will be traveling to your appointment from outside of VA, DC or MD.

Occupation

Emergency Contact Name*

Relationship*

Emergency Contact Phone*

Pharmacy Name*

Pharmacy Address*

Street Address City State ZIP Code

Pharmacy Phone Number

Referring Physician

(If you were referred from a different doctor's office, please enter the doctor's name here. Otherwise leave this field blank)

SMS/Text Message Notification

FCHC (through its secure vendor texting service) can contact you by SMS text message. Texting may include appointment reminders and other care-related messages. Your phone number will never be released to outside parties. To opt-out of SMS text messages I may reply STOP at any time or provide written notice to FCHC.

This field is hidden when viewing the form

Acknowledge TEXT / SMS / Out Out

I acknowledge and understand that I can OPT OUT of SMS text messaging by replying STOP at any time or by providing written notice to FCHC. *

Please type your initials in the box to acknowledge the above regarding opting out of SMS text/messaging.

Medication Abortion (Abortion Pills) .

There is not just one pill taken to end a pregnancy. We use a combination of 2 medications to end a pregnancy: Μifepгistоnе and Μisоpгostоl.

A medication abortion (also known as the “abortion pills”) is a safe and effective method for an abortion through 10 weeks.

Please expect to be in our center for your appointments for about 2 hours on weekdays and 3-4 hours on Saturdays — which includes registration, paperwork, lab services, ultrasound, and receiving the medication from the doctor.

Procedural Abortion (awake or asleep)

What to expect

The doctor will give you the first medication, Μifepгistоnе. This blocks the hormone progesterone which sustains a pregnancy. Without this hormone, the endometrial lining and developing pregnancy shrinks from the uterine wall.

The second medication, Μisоpгostоl, which you will take at home, causes uterine cramping and bleeding (like during your period), helping to expel the ended pregnancy. Cramping and bleeding can be moderate to heavy.

At Our Office: You will swallow the first pill. It is not unusual to have some spotting or even bleeding after the first medication, but the procedure is not yet complete.

At Home: You will take the Μisоpгostоl tablets as directed, helping the uterus to contract and empty. You will take these pills at home. After you take the Μisоpгostоl you will have bleeding and strong cramping that may be severe, dramatic or simply similar to one of your “bad” periods. This may last a few hours.

A heating pad can help with the cramps. You may experience nausea, vomiting, diarrhea, fever, chills, or feel tired. These symptoms usually last only a short time and stop on their own. Everyone’s experience and comfort levels will be different. After two (2) weeks you will complete your follow-up wellness report: either online, by phone or in person.

After four (4) weeks you will take a urine hCG hormone test which will be provided to you.

Medication Abortion - Received*

By checking this box, I acknowledge that I have read and viewed the information above regarding Medication Abortion. I understand that there may be limitations which can affect my suitability for this type of abortion, and the choice about my abortion will be an agreement between my physician and myself. *

A procedural abortion is also called vacuum aspiration. The procedure uses suction to gently remove the pregnancy.

You will receive lab work (height, weight, blood pressure, finger prick)

Our ultrasonographer will complete an ultrasound to date the pregnancy

You will receive 2 pre-medications an hour before the procedure

The procedure itself takes only 5-10 minutes and can be done awake or asleep. Awake procedures use lidocaine (numbing) to numb the cervix but they are given as injections. Asleep procedures are done with an anesthetist/anesthesiologist who puts you to sleep.

You will recover in the patient lounge until you feel ready to go home

Procedural Abortion - Received*

By checking this box, I acknowledge that I have read and viewed the information above regarding Procedural Abortion. I understand that there may be limitations which can affect my suitability for this type of abortion, and the choice about my abortion will be an agreement between my physician and myself. *

NOTE: Your answer above does not commit you to any specific type of abortion procedure. You will be discussing this further with members of our team who will work with you personally to assess which options are available to you.

From the information you have reviewed so far, which type of abortion are you interested in?*

Medication Abortion (Abortion Pill)

Procedural Abortion - Local Anesthesia (awake)

Procedural Abortion - IV Sedation (asleep)

I am still not sure which would be best for me

Appointment Cancellation Policy (BETA)

We ask that patients give us as much notice as possible if they cannot make their scheduled appointment. Please call us if we can help to re-schedule your appointment.

Please type your initials in the box to acknowledge that you have read and understand FCHC's appointment cancellation policy.*

Type your initials in the box.

Disclosure of Alternatives, Benefits and Risks

Please read the following and check the box below to indicate that you've received this information.

You can also obtain a PDF of this document here. (English / Español)

Falls Church Healthcare Center provides abortioncare services by Medication (through 9-11 weeks) or Procedural Abortions (to 15 weeks). Please review this information carefully and review the additional information and videos in our website’s Patient Center. You will have opportunities to discuss this important information with your Patient Educator during your virtual Telehealth appointment or in person on the day of your abortioncare.

ALTERNATIVES TO ABORTIONCARE: We trust that our patients can consider the alternatives, benefits and risks to make an informed choice about their pregnancy. If you are pregnant, you have three basic choices: Choice A: Continue the pregnancy to become a parent. Choice B: Continue the pregnancy and arrange for temporary foster care or an adoption, either within your family or through an agency. Choice C: End the pregnancy now by having an abortion. In addition to abortioncare, Falls Church Healthcare Center provides miscarriage management, interim prenatal care, referrals for pre-natal care and adoption facilitation services as part of our gynecology and reproductive health practice. The decision of which abortioncare method to choose is a completely personal choice. There are two common, very safe methods for ending a pregnancy: Medication abortion in which you ingest pills; one in our office the other at your home Procedural abortion in which a clinician uses aspiration techniques to empty your uterus in our office

BENEFITS TO ABORTIONCARE: Abortion has various benefits, depending upon the individual: •Abortion allows you to have freedom to determine when, if and how you want to be pregnant. •Abortion allows you to resume your normal activities in a short time after the procedure, whether medication abortion or procedural abortion. •Abortion allows you to plan for/choose when is the best time to be pregnant, considering your economic, emotional and physical health. Benefits of medication abortion. It is a safe and effective way to end a pregnancy. It can be completed in the privacy of your home and does not require a pelvic exam. How well does medication abortion work? It depends how far along you are in your pregnancy. The boxes below tell you how well medication abortion works by week of pregnancy

8 weeks or less About 98 out of 100 times From 8 to 9 weeks About 96 out of 100 times From 9 to 10 weeks About 91 to 93 out of 100 times

Benefits of procedural abortion: It is a safe and effective way to end a pregnancy. With the aspiration procedure, the abortion is completed by the time you leave the medical office. How well does aspiration abortion work? The procedure is almost 100% effective, you can expect to no longer be pregnant when you leave the medical office after your procedure.

RISKS OF PREGANCY AND ABORTIONCARE:

GENERAL SAFETY: According to the best medical evidence available, abortion is safer than getting a dental procedure or cosmetic surgery and much safer than childbirth. According to that evidence, in the United States, a woman is about 15 to 25 times more likely to die in childbirth than she is during an abortion. (National Abortion Federation)

GENERAL RISKS: All medical procedures have known and unknown risks. Whether a pregnancy ends by abortion, miscarriage, or childbirth – risks, complications, adverse events and side effects are possible. Whether a pregnancy ends by abortion, miscarriage, or birth, there are risks to one’s health. Weighing the alternatives, benefits and risks is a personal process. Please refer back to our website (fallschurchhealthcare.com) if you are unsure about your decision. Complications of pregnancy, including death are greater from childbirth than from induced abortion.

Patients receiving procedural abortions: 97% report no complications; 2.5% have minor complications that can be handled at the medical office; and less than 0.5% have a more serious complication that requires some additional procedures and/or hospitalization. Patients receiving medication abortions have an excellent safety profile as well, with serious complications occurring in less than 0.5% of cases. (National Abortion Federation) There are risks involved with abortion just as there are risks associated with any medical procedure: •Risk of Infection: Abortion (whether spontaneous, surgical or medical) as well as menstruations and childbirth create conditions that increase risk of infection. Most infections are successfully treated with antibiotics when identified promptly. •Known and unknown side effects from administered medications •Emergency treatment for any complication •Tubal (ectopic) pregnancy •Hemorrhage •Emotional reactions

SPECIFIC RISKS: DURING AN ASPIRATION ABORTION (Procedural) the entrance to the uterus (cervix) is slowly opened with smooth, rounded instruments (dilators). The pregnancy is then removed using gentle aspiration (suction). Aspiration abortion is very safe and successful; over 99% of all patients experience a complete abortion. Although rare, possible adverse events (complications) documented throughout the U.S and Canada include: •Hematometra: 1 in 100 cases. Blood clots accumulating in the uterus that cause persistent bleeding and severe cramping. Can easily be treated with a repeat aspiration procedure, medication or simply monitoring. •Uterine infection: 1 in 100 cases. Routinely treated with antibiotics. •Cervical Tear: 1 in 500 cases. May be self-healing or repaired with stitches during procedure. •Perforation: 1 in 1,000 cases. A puncture or tear to the wall of the uterus or other organs. May be self-healing or may require surgical repair or, rarely, hysterectomy (1 in 10,000 cases). •Missed Abortion: 3 in 1,000 cases. Pregnancy continued and requires the abortion to be repeated. Risk of Failure: Studies have proven a failed abortion is rare but can easily completed here at the Center for no additional cost. Treatment could be additional medication, repeated testing or a repeated aspiration. •Incomplete abortion: 1 in 100 cases. Clots from the pregnancy remains in the uterus. Can easily be treated with a repeat aspiration procedure, medication or simply monitoring. •Excessive bleeding: 1 in 2,000 cases. May require a blood transfusion. •Death: 1 in 160,000 cases. These rare deaths are usually the result of such things as adverse reactions to anesthesia, medications, embolism, untreated infection, or uncontrollable bleeding.

DURING A MEDICATION ABORTION (“The Pill”) two medicines are used to end your pregnancy: Mifepristone is taken in our office; Misoprostol is taken at home to help your uterus expel the ended pregnancy. Medication abortion is very safe and successful; over 96% of all patients experience a complete expulsion of the pregnancy within two weeks. Although rare, possible adverse events (complications) include: •Failure of the medications to end the pregnancy: less than 2 of 100 cases. Failure require retreatment or an aspiration procedure to complete the abortion. •Incomplete abortion: 6 in 100 cases. The incomplete expulsion of the products of conception may require additional medication, monitoring or an aspiration procedure to complete emptying of the uterus. •Excessive bleeding: less than 1 in 100 cases. May require additional medication, monitoring or an aspiration procedure, and extremely rarely a transfusion. •Uterine infection: less than 1 in 200 cases. Will require the use of antibiotics. •Death secondary to toxic shock infection with Clostridium sordellii (has occurred in less than 0.001% of cases in the U.S. & Canada). •Risk of Failure: Studies have proven a slow or failed abortion is rare but can easily completed here at the Center for no additional cost. Treatment could be additional medication, repeated testing or an aspiration procedure. It is important that you agree to have additional treatment if the medication abortion fails. •Be advised: There is no verifiable medical evidence that medication abortion can be reversed.

I acknowledge receiving the Disclosure of Alternatives, Benefits, Risks and Side Effects.*

I acknowledge receiving and reading this disclosure of Alternatives, Benefits, Risks and Side Effects. *

AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT

If you would like to review a PDF copy of the consent form, you can find it here (English/Español).

Please type your initials in the boxes following each statement to indicate consent and/or confirm understanding.

Part I. General Information

As the patient, I have the right to receive information about my health condition and the plan of the medical care to be provided by Falls Church Healthcare Center’s (FCHC).

I agree to talk with the Patient Educator or clinician to review my health condition and the procedures and treatments Falls Church Healthcare Center (FCHC) plans for my care, as well as the alternatives, benefits, risks and side effects that may be associated with my planned care.

With pregnancy, there are three options to consider: abortion, adoption and parenting. There are two ways to have an abortion: Medication Abortion (using medicines) and Procedural Abortion (using aspiration). I will discuss these options with the FCHC staff.

I may change my mind any time prior to receiving the first medication before my chosen procedure.

FCHC Medical Staff can disclose all or any part of my medical record 1) to assist in my continuing care or treatments, 2) as required by Virginia Department of Health, compliant with HIPPA and 3) as required by my insurance company, IF I’ve authorized FCHC to bill for services. I may revoke this authorization by providing written notice to FCHC.

FCHC (through its secure vendor texting service) can contact me by SMS text message. Texting may include appointment reminders and other care-related messages. Your phone number will never be released to outside parties. To opt-out of SMS text messages I may reply STOP at any time or provide written notice to FCHC.

In consideration of the services rendered and received, I agree to pay Falls Church Healthcare Center in accordance with the service fees applicable. Payments for completed medical, counseling, telehealth and laboratory services are non-refundable. I acknowledge that if credit card/debit card payment is declined, charged back or fraudulent I am responsible and may be pursued by Falls Church Healthcare Center for the total price of services rendered and received.

Part II. Medical Care Information

I have reviewed Alternatives, Benefits, Risks and Side Effects that may be associated with my planned care, the Anesthesia Consent, Discharge and Follow-up Instructions and videos available on FCHC’s Patient Portal. I can review this information again with a FCHC Patient Educator via telehealth or in person. I may request and receive copies of this information about my medical care.

All medical procedures have known and unknown risks. Whether my pregnancy ends by abortion, miscarriage, or childbirth – risks (complications) are possible though rare, including risks of death though extremely rare. Complications of pregnancy, including death are greater from childbirth than from induced abortion.

I will disclose all medications and drugs I use to the patient educator or clinician. Using methadone, methamphetamine, heroin, cocaine and other drugs may increase side effects from medication and anesthesia risks.

Part III. Declarations and Consent

After considering the alternatives, benefits, risks and side effects, I request abortion services.

IF I qualify, I request to have:

Aspiration Procedural Abortion (Awake) with a local anesthetic administered by a licensed physician

Aspiration Procedural Abortion (Asleep) with Intravenous (I.V.) sedation administered by a licensed anesthesia clinician

Medication Abortion with mifepristone/misoprostol dispensed by a licensed physician

Other or different conditions requiring additional or different procedures or tests than planned may be discovered during the procedure. I understand, whenever possible, these findings will be discussed with me. I consent to provision of those services to ensure my wellness.

Medications can be administered to abort my pregnancy safely. Medications will be identified and explained prior to administration.

Ultrasound: An ultrasound may be performed to assure the pregnancy is in the uterus (not ectopic) and confirm gestational age. This ultrasound does not determine if the pregnancy is healthy nor the gender. I can be advised if the pregnancy is single or multiple.

I want to know if my pregnancy is multiple.

No

Yes

Pain Control: Local anesthetic (lidocaine) or I.V. sedation (propofol) is available for pain relief during aspiration abortion. Risks from I.V. sedation are rare and will be reviewed by the FCHC anesthesia clinician. I will not drive a car, operate machinery or make important decisions until the morning after receiving I.V. sedation.

I will disclose all medications and drugs I use to the patient educator or clinician. Using methadone, methamphetamine, heroin, cocaine and other drugs may increase side effects from medication and anesthesia risks.

Laboratory: I consent to necessary tests that may include Rh typing.

I agree to the administration of Rh immune globulin (Rhogam) if I my blood type is Rh negative, or I can sign a form to refuse. I understand there is a charge for Rhogam.

In accordance with the customary and usual medical practice FCHC will dispose and/or may test any tissue removed during the procedure.

FCHC Medical Director Daniel Noonan MD and/or other FCHC Clinicians and medical assistants can provide my requested medical care, treatments and procedures. FCHC is a teaching facility, so I understand that medical residents, medical students, clinical externs and/or Doulas, will observe and/or participate in my care under the direction and supervision of the FCHC Clinician.

I may withdraw my consent at any time prior to receiving the first medication before my chosen procedure.

I will call FCHC at 703-532-2500 (daytime number) for unanswered questions, concerns or if I have a medical problem, or the after-hours telephone number (410-631-1600) for urgent medical issues.

If I seek emergency treatment or continuing care elsewhere, I understand the cost or fees may be my responsibility (if not covered by insurance).

No licensed clinician has or can make any promise or guarantee regarding the end results of medical care or abortion.

I have sufficient information to give my informed consent to medical treatment and care. All my questions have been answered to my satisfaction.

My initials on each blank indicate I have read (or had read to me), I understand, and I agree with each statement initialed.

My signature indicates I consent and authorize FCHC to provide the care, procedures and treatments requested or indicated above.

You have selected a preference for procedural abortion. Please read through the following Anesthesia Consent.

You have indicated that you are unsure of the type of abortion care at this time. That's okay! Please read through the following Anesthesia Consent form -- in case you choose a procedural abortion -- and check the box acknowledging receipt of this form.

ANESTHESIA and SEDATION CONSENT FORM

I, as the patient or legal representative for the patient, request a regional anesthesia or I.V. sedation service for my pending procedure to minimize pain and discomfort I might otherwise experience.

PLEASE READ CAREFULLY

• I understand that all forms of anesthesia involve some risks and no guarantees can be made regarding the results of my procedure, treatment, or anesthesia. Some, but not all, of the common risks of anesthesia are headache, sore throat and hoarseness, nausea and vomiting, muscle soreness, injury to the eyes/visual loss, and incomplete or inadequate nerve block requiring conversion to another method.
• In addition, instrumentation to safely protect my airway might unavoidably result in dental damage including fracture or loss of teeth, bridge work, dentures, crowns, fillings and or damages to the lips and gums.
• I understand that more serious risks are extremely rare in the Falls Church Healthcare Center setting but they may include, but not limited to, changes in blood pressure, bleeding, infection, drug reaction, nerve injury, awareness under anesthesia, cardiac arrest, brain damage, paralysis, stroke, or death.
• I understand that, while receiving anesthesia, conditions may develop that would require invasive monitoring or further anesthetic intervention in order to provide for my health and safety.
• I understand that my care will be provided either directly by the attending anesthesiologist or CRNA (Certified Registered Nurse Anesthetist), under the direction of Falls Church Healthcare Center’s Medical Director or assigned or my doctor.
• As required by the Virginia Code 5-412-160, a list of medications, drugs, and their benefits and risks used for your anesthesia and care is to be available.

MONITORED ANESTHESIA CARE WITH SEDATION

Expected result: Reduce anxiety and pain, partial or total amnesia.
Technique: Drug injected into blood stream, or by other routes producing a semi-conscious state.
Rare Risks: An unconscious state, depressed breathing, injury to blood vessels.

REGIONAL ANESTHESIA WITHOUT SEDATION

Expected result: Temporary loss of feeling and/or movement of regional area.
Technique: Drug injected into cervix or the area to be treated.
Rare Risks: Infections, convulsions, persistent numbness, residual pain, injury to blood vessels.

Patient or Legal Representative Certification: I have disclosed any prior adverse reactions to anesthesia and have disclosed my allergies. I have disclosed all medications and drugs I use. I understand using methadone, methamphetamine, heroin, cocaine and other drugs may increase anesthesia risks. I hereby consent to have regional anesthesia, or I.V. sedation and authorize that it be administered by FCHC’s licensed Sedation Clinician or Doctor. I also consent to alternative types of anesthesia, if necessary, as deemed appropriate by them. I understand the contents of this document, agree to its provisions, consent to the administration of anesthesia, and I am knowledgeable of its risks and benefits. I have been given the opportunity to ask any questions I may have. All of my questions have been answered satisfactorily.

By checking this box I acknowledge receiving and reviewing the Anesthesia Consent form which will be signed during my in-person appointment.*

By checking this box I acknowledge receiving and reviewing the Anesthesia Consent form which will be signed during my in-person appointment. *

Aftercare

You indicated an interest in Medication Abortion. Please see the aftercare instructions below. If you have any questions you will have an opportunity to discuss this with your patient educator.

Today At FCHC: During your appointment at FCHC you were administered the Abortion Pill (Mifepristone). This may cause bleeding. Within 48 hours At Home: You were dispensed 4 Misoprostol tablets to take as directed at home, even if bleeding had started.

What to Expect • Cramping, bleeding and spotting are expected during your Medication Abortion treatment. • 2 to 48 hours after taking Misoprostol at home you will experience severe-to-mild bleeding and increased cramping, lasting 4-8 hours • Very severe cramping, much more than a usual period is common, especially as clots and pregnancy tissue is expelled • Chills, fever, nausea, vomiting and/or diarrhea are common side effects of the medicines. • Bleeding decreases within 48 hours. Irregular bleeding and spotting may continue for 6-8 weeks until your next period. • If persistent spotting and bleeding concerns you please call us. You can also note it on your 2-week Follow-Up Wellness Report. • Pregnancy hormones gradually decrease so pregnancy symptoms subside within 10-14 days, but a Urine hormone test will continue to read positive for 4 to 6 weeks.

What to Avoid • Pads should be used during your procedure to monitor bleeding. FCHC suggests you avoid tampons or menstrual cycle cups until bleeding has slowed down and you are only spotting. • Do not use vaginal medications or suppositories unless you have checked with your physician. Do not douche. • FCHC suggests refraining from sexual activity for the next 7 days.

How To Recover Quickly And Easily • Return to your normal activities as soon as you can. You do not need bed rest. You may shower and take baths. • Enjoy fresh air and exercise. Regular walks and light exercise can help decrease cramping. • Treat cramping with Ibuprofen. A cold pack or heating pad on the abdomen or lower back is helpful. You can also massage your abdomen to relieve discomfort. • Strenuous activity (heavy lifting, exercise) may increase bleeding. This is normal.

Additional Important Information • You can expect a period in 4-8 weeks after your abortion. • Your first period will be heavier and longer, will include small clots with heavier cramping than usual. This is normal. • Contraception information: www.bedsider.org/methods .Pregnancy can occur before your next period. • Urine pregnancy hCG hormone tests will be positive up to 4-6 weeks. Call if concerned. • Discounted fees are available for continuing GYN services

CALL US IF YOU EXPERIENCE • Persistent fever - 100.4 or higher for 3 hours or more • Severe persistent cramping or pain not helped by medication • Very heavy bleeding: SOAKING 2 maxi pads every hour for 3 hours or more. • Persistent vomiting or diarrhea 24 hours after misoprostol • Severe malaise or weakness 48 hours after misoprostol • Persistent pregnancy symptoms after 2 weeks. Or if you do not have a period by 8 weeks.

What Can I Expect At Home?

BLEEDING: You can experience bleeding that lasts for 5-7 days, then experience spotting that lasts for an additional week or more.The amount of bleeding will vary for each person. For some patients, the bleeding stops and starts for a few days at a time. Others may not have bleeding at all. It is normal to pass clots while bleeding. Spotting could persist until your next menstrual cycle.

CRAMPS: Many patients experience cramping similar to their menstrual cycle cramps or stronger. As needed, you may take over the counter medications containing ibuprofen, naproxen or acetaminophen to help with discomfort. Take these medications according to manufacturer's instructions.

CHANGE IN HORMONES: Pregnancy hormones gradually decrease and pregnancy symptoms will subside within 10-14 days.

What do I need to Avoid? • Pads should be used after your procedure to monitor bleeding. FCHC suggests you avoid tampons or menstrual cycle cups until bleeding has slowed down and you are only spotting. • Do not use vaginal medications or suppositories unless you have checked with your physician. Do not douche. • If you had IV sedation, avoid driving for 24 hours • FCHC suggests refraining from sexual activity for the next 7 days.

What should I do to recover quickly and easily? • Return to your normal activities as soon as you can. You do not need bed rest. You may shower and take baths. • Enjoy fresh air and exercise. Regular walks and light exercise can help decrease cramping. • Treat cramping with Ibuprofen. A cold pack or heating pad on the adomen or lower back is helpful. You can also massage your abdomen to relieve discomfort. • Strenuous activity (heavy lifting, exercise) may increase bleeding. This is normal.

Additional Important Information • You can expect a period in 4-8 weeks after your abortion. • Your first period will be heavier and longer, will include small clots with heavier cramping than usual. This is normal. • Contraception information: www.bedsider.org/methods • Pregnancy can occur before your next period. • Urine pregnancy hCG hormone tests can be positive up to 4-6 weeks. Call if concerned. • Discounted fees are available for continuing GYN services

CALL US IF YOU EXPERIENCE • Persistent fever - 100.4 or higher for 3 hours or more • Severe persistent cramping or pain not helped by medication • Very heavy bleeding: SOAKING a maxi pad every hour and/or passing 4 or more large clots walnut size or larger for 2 hours or more. • Persistent vomiting or diarrhea for 24 hours • Persistent pregnancy symptoms after 2 weeks. • If you do not have a period by 8 weeks.

By checking this box I acknowledge receiving and reviewing abortion aftercare instructions. I will have an opportunity to review this with a patient educator.*

By checking this box I acknowledge receiving and reviewing abortion aftercare instructions. I will have an opportunity to review this with a patient educator. *

Insurance Authorization Form

Will insurance be used for some or all payment for your abortion care?*

Yes

No

Medicaid or government insurance cannot be used for abortion.

Consent - Insurance*

By checking this box, I acknowledge that I have read, understand and agree to this Participation and Authorization Agreement*

Using my Insurance: Falls Church Healthcare Center (FCHC), as a service for you, will file your claim for payment of your medical care with your listed Insurance Carrier. Although we rely on your insurance company’s good faith pre-authorizations, verifications, certifications and coverage approvals and their reported co-pay, co-insurance and deductible amounts the claim may still be denied by your insurance company or some services not covered once FCHC files your claim. Your insurance plan is a contract between you and your insurance company. We must hold you responsible for any balances due. If your policy includes a co-insurance, a co-pay or deductible amount, that is determined by your insurance company and collected by FCHC at the time of service. If our office does not hear from your insurance company within 30 days, we may request your help in contacting your insurance company to resolve the payment delay. Please supply your insurance card and a photo I.D. at each office visit.

Authorization for Release of Information: I authorize Falls Church Healthcare Center to disclose all or any parts of my medical record to my listed insurance company(s) and any review agency which conducts practice utilization review under a HIPPA agreement with patient’s payment source. I also understand that I may revoke this authorization by providing written notice to Falls Church Healthcare Center.

Laboratory Billings: Your services may include laboratory studies required by your insurance company and or requested as a standard of care by your clinician. Your clinician will discuss the recommended additional tests as part of your care. Though the specimens may be collected at FCHC, these studies are NOT conducted at FCHC but sent to and conducted by an independent laboratory. That independent laboratory will file a claim to your insurance company separately. Any unpaid deductibles, co-insurance and copay as well as denials by your insurance company for those laboratory studies will be billed to you separately by the independent laboratory and will be your financial responsibility.

Payment of Services: I understand I am financially responsible for all charges and fees related to the services provided to me by FCHC. I understand that laboratory services if any that are provided by other than FCHC may incur charges separately billed by the laboratory. I further understand that payment in full for any unpaid amount is expected upon receipt of Falls Church Healthcare Center’s first invoice. The invoiced charges may include unpaid co-payments, to be billed co-insurance amounts, unpaid deductibles and any fees for services not covered or denied by your insurance company such as medications and anesthesia. I understand I can request a payment plan to be arranged. I understand that 10% late fees may be attached to unpaid balances. I understand I am financially responsible for any legal fees and collection service fees related to the collection of my overdue outstanding balances.

Assignment of Benefits: I hereby authorize and request that my insurance company(s) make payment for my medical care directly to the Falls Church Healthcare Center or its assigns. In the event an overpayment is made from more than one insurance company, I understand the overpayment will be sent to the appropriate payor

This field is hidden when viewing the form

Insurance Authorization Form (BETA)

[reblex id='5006']

Will you be using insurance to pay for your appointment (in part or in full)?

No

Yes

Please note that Medicaid or any government insurance will not pay for abortion care.

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Who is the insurance policyholder?

Policyholder Name

First Last

Policyholder Date of Birth

Insurance Provider

Insurance: Other

Member ID / Policy #

Group #

Provider Benefits Phone Number (on the back of the card)

In order to save time at your in-person appointment, please provide a photo of both sides of your insurance card and the front of your photo ID. Your images will be submitted and transmitted securely.

Front of Insurance Card

Max. file size: 2 GB.

Back of Insurance Card

Max. file size: 2 GB.

Front of License / Government ID

Max. file size: 2 GB.

HIPAA PRIVACY PRACTICES:

SUMMARY OF PATIENT RIGHTS AND RESPONSIBILITIES

➢ Your medical information is protected. It will be kept confidential and is only used or disclosed for treatment that will ensure your care and wellness.
➢ We may leave messages for you regarding your medical care or next appointment with us via voice mail or text messaging, unless indicated otherwise.
➢ We will supply appropriate and necessary information to insurance companies and/or financial companies if needed.
➢ You have the right to access and obtain copies of your health information records, including amending authorization to whom medical information may be released.
➢ If you believe your privacy rights have been violated, you may file a complaint. Filing a complaint will not infringe on your patient care or privacy rights. No action will be taken against you for filing a complaint.
➢ This is a summary of your privacy practices. The full text is available to you today on paper or online at: fallschurchhealthcare.com/privacy-policy.

HIPAA*

By checking this box, I acknowledge that I have read this summary of my privacy rights. I understand my rights and responsibilities as well as the privacy practices at the Falls Church Healthcare Center. I understand the full text of FCHC’s patients rights are available to me at: fallschurchhealthcare.com/privacy-policy or by request at the front desk. *

Language

Which language do you prefer your forms be printed in?

English

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Signature and Date

Please confirm that you acknowledge all of the above information by supplying your signature (which you can draw with your finger or the mouse) and today's date.

You will have an opportunity to review these forms and your signature at your in-person appointment.

Signature

Today's Date

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Today's Date

It may take up to 1 minute when you submit the form before you get a confirmation message. There's a lot of information to process! Please be patient and don't click Submit more than once. Thanks!

900 South Washington Street, Suite 300, Falls Church, VA 22046

(703) 532-2500