Forms

Appointment Forms

In an effort to save you time, we have provided several forms to help you prepare for your appointment. Filling out the forms ahead of time and making sure they are completed to the best of your ability can save you up to 30 minutes in the clinic. Please complete the forms that best represent your upcoming appointment and bring it with you to help reduce your waiting time.

NOTE: The following forms are made available to you online in Adobe Acrobat Reader. Access www.adobe.com for a FREE download.

For more information about forms, please click here to contact us. Or select

Abortion Patients

There are some forms we cannot place online but filling out the following forms and bringing them into our office will reduce your wait time. Information documents must be read, printed and brought with you at the time of your appointment.

Abortion Pill Patients: Please read carefully, sign and date.

Patient Registration

Mifeprex - Patient Information

Mifeprex - Patient Agreement

Mifeprex - 24-Hour Informed Consent

Notice of Privacy Practices

Surgical Abortion Patients: Please read carefully, sign and date.

Patient Registration

Surgical Patient Information

Disclosure of Risks and Informed Consent

Request for First Trimester Abortion

Anesthesia Informed Consent

Patient Visitation Guidelines

Driver Verification Form

Follow Up Care

Notice of Privacy Practices  

Miscellaneous Forms: See specific instructions.

Authorization for Medical Records Release
Please print out, fill out completely and fax back with copy of photo ID.

Credit Card Release
Please print out, fill out completely and fax back with copy of photo ID and front/back of credit card.

Minor Notification by Parent Guardian
This form must be notarized and brought the day of the patient's appointment. Notary is available on premises Tuesday - Friday. Patients scheduled for Saturdays must have this form notarized in advance.