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  • ABORTION PILL
  • PROCEDURAL ABORTION
    • Awake (through 12 weeks)
    • Asleep (through 15 weeks)
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  • ABORTION PILL
  • PROCEDURAL ABORTION
    • Awake (through 12 weeks)
    • Asleep (through 15 weeks)
  • FEES
  • SERVICES
    • Abortion Options Counseling
    • Doula
    • Gynecological Care
    • Other Care
  • ABOUT
    • Who We Are
    • Telehealth
    • Tour Our Center
    • Video Resources
    • DONATE
  • PATIENT CENTER
    • Request An Appointment
    • Reschedule / Change An Appointment
    • Patient Information Forms
    • Provide Follow-Up Status
    • Financial Assistance
    • Pregnancy Calculator
  • CONTACT US
  • Español

© 2019

Patient Intake Forms

1 General Information
2 Abortion Types: Medical
3 Abortion Types: Procedural
4 Abortion Types: Preference
5 Medical History
6 Demographic Info (Abortion only)
7 Alternatives, Benefits and Risks (Abortion Only)
8 Patient Consent (Abortion Only)
9 Anesthesia / Sedation Consent (Procedural Abortion Only)
10 Aftercare Instructions (Abortion Only)
11 Insurance Authorization Form
12 HIPAA - Privacy Policy / Signature
  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 100.
  • You indicated you are under 18. There are a few additional requirements and steps for patients under 18 to receive abortion care in Virginia.

    Please read through our Information for Patients Under 18 section for forms and details. One of our patient educators can also help explain the process; please feel free to call 703-532-2500 or email womenfirst@fallschurchhealthcare.com  to speak with one of our patient educators.

  • 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.
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  • Medication Abortion (Abortion Pill)

    A mediction abortion is a safe and effective method for an abortion through 9 weeks.

    At Falls Church Healthcare we use a combination of 2 medications to end a pregnancy: Mifepristone and Misoprostol

    Completing the medication abortion procedure itself only takes 5-10 minutes. However, you should expect to be in our center for your appointments for 2-3 hours — which includes registration, paperwork, lab services, procedure review and your actual abortioncare appointment.

    You will have an opportunity to meet with your patient educator to discuss the procedure and your feelings and concerns prior to this appointment. Our staff is here to support and help both patients and those who are with you in this experience.

    What to Expect:

    1. At your abortioncare appointment our clinician will give you the first medication, Mifepristone. This blocks the hormone progesterone which sustains a pregnancy. Without this hormone, the endometrial lining and developing pregnancy shrinks from the uterine wall.
    2. The second medication, Misoprostol, which you will take at home, helps the cervix soften and uterine cramping and bleeding (like during your period) begins helping to expel the ended pregnancy. Cramping and bleeding be moderate to heavy.

    At Our Office:  You will swallow the first pill Mifepristone (also known as ‘the abortion 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 Misoprostol tablets, which are taken orally, helping the uterus to contract and empty. You will take these pills 12 to 48 hours later, considering your clinician’s recommendations and your personal schedule. After you take the Misoprostol 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.
    • You may be given a prescription by your physician for pain management to be filled at your pharmacy.

    Aftercare:  Plan to follow up by phone in 2 to 3 weeks. It is very important for patients to have a follow-up examination especially if pregnancy symptoms have not decreased.

    There are options for your follow-up assessment to verify you have successfully expelled your pregnancy tissue completely which we can review with you.

    Additional Information on Abortion Pill (Medication Abortion):

    • National Abortion Federation: I’m Pregnant:  What are the options?
    • National Abortion Federation: First Trimester Abortion: A Comparison of Procedures
    • “Medical Abortion” — a video from Pharmacy5in5:

     

     

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  • Procedural Abortion:

    Awake (Through 12 Weeks)
    Asleep (Through 15 weeks)

    Having a procedural abortion is a SAFE & EFFECTIVE option for ending a pregnancy.

    A procedural abortion, also known as aspiration abortion, is usually administered by a method called vacuum aspiration. The procedure itself usually takes only five to ten minutes, and is a common in-office gynecology service.

    While the procedure itself last only minutes, additional time is needed for registration, paperwork, lab services and recovery. Please plan to be in our office for 3-4 hours for you abortioncare appointment.

    You will have an opportunity to meet with your health educator to discuss the procedure and your feelings and concerns at your appointment. Our staff is here to support and help both patients and those who are with you in this experience.

    In the video below, Dr. Jan Fruiterman, one of the board-certified gynecologists at Falls Church Healthcare Center, explains aspiration abortion:

    What to Expect

    You will be assigned a health educator who serves as your advocate to assist you with paperwork, review your appointment and answer your questions.  At your appointment your sonogram will be obtained and medical history reviewed, lab work is performed and pre-medications given before you are readied for the procedure. These are important opportunities for you to meet your medical team and to relax.

    The abortion procedure will be performed by one of our Board Certified Clinicians. The procedure itself takes only a few minutes and typically is not performed until the embryo is visualized by sonogram, usually after 5-6 weeks gestation.

    • Cervical preparation takes place prior to the procedure through administration of misoprostol which softens the cervix
    • Local anesthesia (awake) or IV sedation (asleep) is administered
    • Sterile medical instruments, a dilator and cannula, are gently inserted through the vaginal cavity, into the cervix opening and into the uterus.
    • The cannula is connected to a device that will provide the gentle suction needed to safely remove the pregnancy tissue from the uterus. This may make a slight, annoying sound.
    • Following the procedure, we allow ample recovery time in our patient’s lounge. You will be discharged with written and oral instructions on how to take care of yourself and what to do if you have a problem.

    BEFORE your abortion procedure

    • Avoid sexual intercourse the day before the procedure
    • Avoid douches 48 hours before the procedure
    • Avoid vaginal creams or medications 1 week before the procedure
    • Please do not wear fingernail polish
    If you’re NOT having I.V.Sedation you will be AWAKE – you can:
    • Take Tylenol or Motrin 30 minutes prior to your appointment time.
    • Drive yourself home.
    If you’re HAVING I.V.Sedation you will be ASLEEP – you must:
    • NOT eat, drink, chew gum (nothing by mouth) 6 hours prior to your appointment. Be sure to drink water before you begin to fast.
    • Please bring someone with you to drive you home…you cannot drive yourself home.
    • Plan to be at the center at least 3-4 hours. You will have a 30 minute recover time in the patient lounge.

    AFTER your abortion procedure

    • Harmless vaginal bleeding and some discomfort is possible immediately after the procedure.
    • Some women may need to use a pad for a few days after the procedure.
    • Comply with the clinician’s instructions for follow-up visits and any needed re-tests.
    • You will be given aftercare instructions that includes no sexual activity for at least 1 week.

    About 2-3 weeks after your procedure, please call FCHC for a follow-up phone appointment.

    Please Note: Completing a urine pregnancy test prior to calling will help our nurse in your follow-up assessment.

    We encourage and will assist you in exploring various family planning / birth control options.

    Additional Information about Procedural Abortion using Vacuum Aspiration

    • National Abortion Federation: I’m Pregnant:  What are the options?
    • National Abortion Federation: First Trimester Abortion: A Comparison of Procedures
    • How does procedural abortion work?

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  • 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.
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  • Medical History

  • (This is just an approximation. We will be taking measurements at your in-person appointment.)
  • (This is just an approximation. We will be taking measurements at your in-person appointment.)
  • Please list the number of each type of pregnancy. If none, indicate 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Please enter a number greater than or equal to 0.
  • Menstrual History
  • Date Format: MM slash DD slash YYYY
  • Please enter a number greater than or equal to 0.
  • Contraceptive History

  • Initial


  • The privacy standards established by 2003 HIPPA Provisions address the privacy and security of patient data.

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  • Patient Demographic Information

    The information in this box is submitted to the Division of Vital records, Virginia Department of Health. No identifying information will be submitted.
  • The information in this box is submitted to the Division of Vital records, Virginia Department of Health. No identifying information will be submitted.

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  • 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 ABORTIONCARE

    Falls Church Healthcare Center provides abortioncare services by Medication (through 9 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 Abortion 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.

     

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  • 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

  • Part II. Medical Care Information

  • Part III. Declarations and Consent

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  • 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

    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.

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  • 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.

    You can also download the instructions here.

    Your Care at Home

    Medication Abortion

    You can also download a PDF of this form locally here.

    It is important to have a follow-up assessment of your wellness after your at-home abortion to ensures you are well and that you have had bleeding and the pregnancy has passed from your uterus without complications.

    Please complete a follow-up three weeks following your abortion appointment by calling 703-532-2500 or by visiting https://fallschurchhealthcare.com/follow-up. Taking a urine pregnancy test prior to your follow-up will help our nurse in your follow-up assessment.

    What medications are used?

    • Mifeprex (Mifepristone): This medication blocks the hormone progesterone, that sustains a pregnancy. Without this hormone, the endometrial lining and developing pregnancy shrinks from the uterine wall. It is possibly to have bleeding after taking this pill. You are to take Misoprostol even if you have started to bleed.
    • The second medication, Misoprostol (which you will take at home) helps the cervix soften. This medication will help expel the ended pregnancy and menstrual tissue by bleeding and cramping.

    How do I take the mediation at home?

    • Take your four Misoprostol tablets as discussed with your Doctor.
    • If you can, choose a time when you have had a good meal and plenty of rest.
    • Wear a maxi pad and stay hydrated.

    What should I expect at home?

    After taking Mifepristone most women experience few side effects:

    • Chills, Nausea and diarrhea are possible but rare.’
    • Some women report cramping & bleeding or spotting after taking this pill. If this is happens, still take the Misoprostol at home as directed.
    • After taking the Misoprostol at home women may experience severe to mild cramping then bleeding.
    • This bleeding and cramping usually begins in 2 to 48 hours after taking the misoprostol.
    • Your cramping may be much more than with your period.
    • Very severe cramps are normal, especially when pregnancy tissue is passing.
    • Manage your cramps with NSAIDS or the prescription pain reliever your doctor gave you.
    • Your bleeding may be much more than with your period. Your bleeding usually decreases to a light flow within 48 hours however, bleeding & spotting may continue for 6-8 weeks. We can discuss this at your follow-up if it concerns you.

    What should I do to recover quickly and Easily?

    • Return to your normal daily activities. Enjoy fresh air and walks.
    • Stay hydrated, have good meals and get rest
    • To avoid increase risk of infection or unintended pregnancy avoid sexual activity for at least 7 days or until your follow-up.

    When should I call? Please keep and re-read your Medication Guide. Call us if you have:

    • A temperature of 100.4 F or higher for 2 hours in a row.
    • Very heavy bleeding: soaking 2-3 maxi pads an hour for 2-3 hours in a row.
    • Persistent nausea, vomiting, diarrhea, or extreme weakness more than 24 hours after taking Misoprostol at home.
    • If you are concerned at any point between now & your follow-up, please call us.
    • If you cannot reach your healthcare provider, go to the nearest hospital emergency room. Take your Mifeprex medication guide with you.

    When will my period come back? You can expect a period in 4 – 8 weeks, though you may ovulate before then.

     



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

    You can also download aftercare instructions here.

    Your Care at Home

    Procedural Abortion

    You can also download a PDF of this form locally here.

    What Can I Expect At Home?

    • Bleeding: You can experience bleeding that lasts for 5-7 days, then experience spotting that lasts for a week or more. The amount of bleeding will vary. For some, 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 experience cramping similar to their menstrual cycle cramps. If 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: Your body will be undergoing some changes due to the gradual decrease in the pregnancy hormones.  Pregnancy symptoms usually subside within 10-14 days.

    What Do I Need To Avoid?

    • Avoid driving for 24 hours (if you had IV sedation).
    • FCHC suggests refraining from sexual activity for the next 7 days.
    • 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.

    What should I do to recover quickly and easily?

    • Return to your normal activities as soon as the next day. You do not need bed rest.
    • You may shower and take baths.
    • If you experience cramping, applying heat or a cold pack may help. Use a heating pad on your abdomen or lower back. You can also massage your abdomen to relieve discomfort. Regular walks and light exercise could help decrease cramping as well.
    • Sometimes with strenuous activity (like heavy lifting and exercise) your bleeding may increase. This doesn’t happen for everyone. This is normal.

    Additional Important Information:

    • You should have your period 4-8 weeks after the procedure.
    • It is possible to become pregnant before your next period.
    • A urine pregnancy test may show a positive reading up to a four weeks after your procedure. This may be due to the gradual decrease in the pregnancy hormones. Call us if you have concerns.
    • We provide a discounted rate for continuing your gynecologic healthcare needs with us.

    Call us if you have any concerns or:

    • If you have a temperature of 100.4 or higher
    • Experience severe cramping or pain not helped by medication
    • Experience very heavy bleeding (soaking a maxi pad every hour for two hours in a row)
    • Experience vomiting or diarrhea that persists for 24 hours
    • Do not have your period within 8 weeks of your procedure or if pregnancy symptoms persist.

    It is important to have a follow-up assessment of your wellness after your abortion to ensure you are well and that you have no complications.

    Please complete a follow-up three weeks following your abortion appointment by calling 703-532-2500 or by visiting https://fallschurchhealthcare.com/follow-up. Taking a urine pregnancy test prior to your follow-up will help our nurse in your follow-up assessment.

     



  • You indicated that you're not yet sure which type of abortion is right for you. Below are the aftercare instructions for both Medication (Abortion Pill) and Procedural abortion. You'll have an opportunity to discuss your options further with your patient educator to help you make the best decision.

    You can also download the aftercare instructions here:

    • Medication
    • Procedural

    Your Care at Home

    Medication Abortion

    You can also download a PDF of this form locally here.

    It is important to have a follow-up assessment of your wellness after your at-home abortion to ensures you are well and that you have had bleeding and the pregnancy has passed from your uterus without complications.

    Please complete a follow-up three weeks following your abortion appointment by calling 703-532-2500 or by visiting https://fallschurchhealthcare.com/follow-up. Taking a urine pregnancy test prior to your follow-up will help our nurse in your follow-up assessment.

    What medications are used?

    • Mifeprex (Mifepristone): This medication blocks the hormone progesterone, that sustains a pregnancy. Without this hormone, the endometrial lining and developing pregnancy shrinks from the uterine wall. It is possibly to have bleeding after taking this pill. You are to take Misoprostol even if you have started to bleed.
    • The second medication, Misoprostol (which you will take at home) helps the cervix soften. This medication will help expel the ended pregnancy and menstrual tissue by bleeding and cramping.

    How do I take the mediation at home?

    • Take your four Misoprostol tablets as discussed with your Doctor.
    • If you can, choose a time when you have had a good meal and plenty of rest.
    • Wear a maxi pad and stay hydrated.

    What should I expect at home?

    After taking Mifepristone most women experience few side effects:

    • Chills, Nausea and diarrhea are possible but rare.’
    • Some women report cramping & bleeding or spotting after taking this pill. If this is happens, still take the Misoprostol at home as directed.
    • After taking the Misoprostol at home women may experience severe to mild cramping then bleeding.
    • This bleeding and cramping usually begins in 2 to 48 hours after taking the misoprostol.
    • Your cramping may be much more than with your period.
    • Very severe cramps are normal, especially when pregnancy tissue is passing.
    • Manage your cramps with NSAIDS or the prescription pain reliever your doctor gave you.
    • Your bleeding may be much more than with your period. Your bleeding usually decreases to a light flow within 48 hours however, bleeding & spotting may continue for 6-8 weeks. We can discuss this at your follow-up if it concerns you.

    What should I do to recover quickly and Easily?

    • Return to your normal daily activities. Enjoy fresh air and walks.
    • Stay hydrated, have good meals and get rest
    • To avoid increase risk of infection or unintended pregnancy avoid sexual activity for at least 7 days or until your follow-up.

    When should I call? Please keep and re-read your Medication Guide. Call us if you have:

    • A temperature of 100.4 F or higher for 2 hours in a row.
    • Very heavy bleeding: soaking 2-3 maxi pads an hour for 2-3 hours in a row.
    • Persistent nausea, vomiting, diarrhea, or extreme weakness more than 24 hours after taking Misoprostol at home.
    • If you are concerned at any point between now & your follow-up, please call us.
    • If you cannot reach your healthcare provider, go to the nearest hospital emergency room. Take your Mifeprex medication guide with you.

    When will my period come back? You can expect a period in 4 – 8 weeks, though you may ovulate before then.

     


    Your Care at Home

    Procedural Abortion

    You can also download a PDF of this form locally here.

    What Can I Expect At Home?

    • Bleeding: You can experience bleeding that lasts for 5-7 days, then experience spotting that lasts for a week or more. The amount of bleeding will vary. For some, 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 experience cramping similar to their menstrual cycle cramps. If 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: Your body will be undergoing some changes due to the gradual decrease in the pregnancy hormones.  Pregnancy symptoms usually subside within 10-14 days.

    What Do I Need To Avoid?

    • Avoid driving for 24 hours (if you had IV sedation).
    • FCHC suggests refraining from sexual activity for the next 7 days.
    • 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.

    What should I do to recover quickly and easily?

    • Return to your normal activities as soon as the next day. You do not need bed rest.
    • You may shower and take baths.
    • If you experience cramping, applying heat or a cold pack may help. Use a heating pad on your abdomen or lower back. You can also massage your abdomen to relieve discomfort. Regular walks and light exercise could help decrease cramping as well.
    • Sometimes with strenuous activity (like heavy lifting and exercise) your bleeding may increase. This doesn’t happen for everyone. This is normal.

    Additional Important Information:

    • You should have your period 4-8 weeks after the procedure.
    • It is possible to become pregnant before your next period.
    • A urine pregnancy test may show a positive reading up to a four weeks after your procedure. This may be due to the gradual decrease in the pregnancy hormones. Call us if you have concerns.
    • We provide a discounted rate for continuing your gynecologic healthcare needs with us.

    Call us if you have any concerns or:

    • If you have a temperature of 100.4 or higher
    • Experience severe cramping or pain not helped by medication
    • Experience very heavy bleeding (soaking a maxi pad every hour for two hours in a row)
    • Experience vomiting or diarrhea that persists for 24 hours
    • Do not have your period within 8 weeks of your procedure or if pregnancy symptoms persist.

    It is important to have a follow-up assessment of your wellness after your abortion to ensure you are well and that you have no complications.

    Please complete a follow-up three weeks following your abortion appointment by calling 703-532-2500 or by visiting https://fallschurchhealthcare.com/follow-up. Taking a urine pregnancy test prior to your follow-up will help our nurse in your follow-up assessment.

     

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  • Insurance Authorization Form

  • Insurance 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.

     As of February 22, 2021, Falls Church Healthcare Center accepts the following Insurance Carriers:

    AETNA (HMO, PPO, POS, EPO, HDHP, HSA) CareFirst Administrators
    AETNA Coventry Cigna (HMO, PPO, OAP, SAR)
    AETNA Signature Administrators First Health Network (Emergency GYN Only)
    Anthem Blue Cross Blue Shield  (HMO, PPO, POS, HDHP) HealthSCOPE Benefits
    Anthem Healthkeepers (HMO) Innovation Health
    Anthem Healthkeepers Plus (GYN Only) Meritain Health (GYN Only)
    CareFirst Blue Cross Blue Shield (HMO, PPO, Blue Choice Advantage, Blue Choice Plus) Multiplan (Beech Street, PHCS) (GYN Only)

    If you are not sure if your Insurance Policy includes pregnancy or gynecology benefits, we recommend that you call your policy customer service number on the back of your insurance card for clarification.

    • Medicare, Medicaid and federal government insurance plans do not cover abortioncare unless medically necessary.
    • First Health Network International is travel Insurance so only covers injury or illness not related to routine gynecological wellness services.
    • Carriers we currently are unable to accept for abortioncare or GYN services include:
      • Cigna – EPO Connect
      • Golden Rule
      • United Health Care
      • One Net Alliance
      • Optimum Choice
    • If you are not sure if your Insurance Policy includes pregnancy or gynecology benefits, you can call your policy customer service number on the back of your insurance card for clarification.

    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.

     

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  • 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.
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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.

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