Sample Multi-Page Form

Select your appointment type:*
- Option 1
- Option 2
Patient's Full Name*
First Last
Date of Birth
MM slash DD slash YYYY
Age
Please enter a number from 0 to 100.
Minor Patient Acknowledgment
- By checking this box I acknowledge that I have read the information above and will read through the Information for Patients Under 18. *
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
Occupation
Emergency Contact Name
Relationship
Emergency Contact Phone
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.
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.

MedAb Page
Medication Abortion - Received*
- checkbox 1

ProcAb Page
Procedural Abortion - Received*
- Checkbox 2

From the information you have reviewed so far, which type of abortion are you interested in?
- Option 1
- Option 2
- Option 3
- Option 4
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.

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)
"alternatives-benefits-and-risks-of-abortion-care"
I acknowledge receiving the Disclosure of Alternatives, Benefits, Risks and Side Effects.*
- Checkbox 4

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.
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 form and check the box acknowledging receipt of this form. You can also download this form locally here.
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. You can also download this form locally here.
ANESTHESIA and SEDATION CONSENT FORM
By checking this box I acknowledge receiving and reviewing the Anesthesia Consent form which will be signed during my in-person appointment.*
- Checkbox 5

Aftercare
MVIP
LVIP
Undecided
By checking this box I acknowledge receiving and reviewing abortion aftercare instructions. I will have an opportunity to review this with a patient educator.*
- Checkbox 6

Insurance Authorization Form
Will insurance be used for some or all payment for your abortioncare?
- Yes
- No
Consent - Insurance*
By checking this box, I acknowledge that I have read, understand and agree to this Participation and Authorization Agreement*

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
- Spanish
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
MM slash DD slash YYYY
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Today's Date
MM slash DD slash YYYY
CAPTCHA
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!

Sample Multi-Page Form

TEST - Pation Forms

SMS/Text Message Notification

Medical History

Contraceptive History

Initial

Patient Demographic Information

Disclosure of Alternatives, Benefits and Risks

AUTHORIZATION & CONSENT FOR MEDICAL TREATMENT

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

Part I. General Information

Part II. Medical Care Information

Part III. Declarations and Consent

ANESTHESIA and SEDATION CONSENT FORM

Aftercare

Insurance Authorization Form

HIPAA PRIVACY PRACTICES:

SUMMARY OF PATIENT RIGHTS AND RESPONSIBILITIES

Language

Signature and Date

Section Break