Consent to complete a virtual Medical Abortion
Please read the consent form carefully, ask all your questions at the virtual appointment, and email us your signed copy. Once all your concerns have been addressed during the virtual intake appointment, we will email you a pdf copy of this form for you to sign. We will need your signed consent in order to proceed with your virtual abortion.
Cabbagetown Women’s Clinic VIRTUAL Medical Abortion Consent Form
I understand that the purpose of today’s medical abortion procedure is to end my pregnancy. I have not been forced by anyone to end this pregnancy. I understand that two medications, mifepristone and misoprostol, are used to induce an abortion. I am being prescribed these medications according to the evidence-based protocols approved by the Society of Obstetricians and Gynecologists of Canada and the National Abortion Federation.
I understand that the complications of medical abortion, while very rare, may occur in spite of the best intentions and skill of the staff of Cabbagetown Women’s Clinic. I have been informed that there is a possible risk of some tissue remaining in the uterus, as well as continuation of pregnancy, which would require a aspiration procedure to complete the abortion. There is also a remote risk of hemorrhage, allergic reaction or error in estimating the duration or existence of pregnancy. I understand that there are also some very remote risks including serious infection, blood transfusion, or rarer still, death and I accept these risks.
I am giving my full consent to the doctor to provide a medical abortion, and for the treatment of any complications, should they arise. I know I should not change my mind about having an abortion after I have taken the abortion pills, since this medication is known to damage growing pregnancies. If the medication fails, CWC strongly recommends that I agree to a surgical abortion or to repeating the medical abortion ONE more time if this is my preference. When I have my 2-3 day follow-up appointment, I will be informed if I need more tests.
I will do a urine pregnancy test at 4 weeks to make sure the pregnancy is completely gone. I have been informed that about 0.5 % of pregnancies grow outside of the uterus; they are called ectopic pregnancies. If a pregnancy is ectopic, the Medical Abortion will not work. This situation may require a different medication or surgery to remove the pregnancy from the fallopian tube.
ECTOPIC PREGNANCY WARNING - Ectopic pregnancies can be dangerous if the pregnancy ruptures and bleeds into the abdomen. It is common to have cramping pain as the pregnancy gets smaller and goes away (reabsorbs) but watch for strong, steady pain on one side that gets worse with movement. If that occurs, I must go to the nearest Hospital Emergency Department and say that I may be at risk of a rupturing ectopic pregnancy. As well, if I experience any of the following symptoms, I must go to the emergency room:
- Lightheadedness, feeling faint or fainting
severe bleeding (more than 2 full pads/hour for more than 1 hour, or blood clots larger than a lemon)
pus coming out of my vagina
I will not hold Cabbagetown Women’s Clinic responsible for loss or injury that may result from failure to follow the instructions I have been given or for anything that happens due to my withholding information about myself. I commit to completing all the necessary follow-up appointments and tests. I have read and understood the above and have had an opportunity to discuss any concerns or questions that I might have. I hereby consent to have a medical abortion at Cabbagetown Women’s Clinic.