Patient Intake Forms

Select your appointment type:*

Abortion Care

Gynecology

Patient's Full Name

First and last name

Preferred Name (Optional)

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

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Date Of Birth (Month/Day/Year)

Age

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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.

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

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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.

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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

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.