Planned Parenthood Abortion Form

The Planned Parenthood abortion form is a document that is used by patients who wish to terminate their pregnancies.

Time to complete

3 minutes

Eligibility

Individuals who are 18 years of age or above and have been diagnosed with an unplanned pregnancy can fill the Planned Parenthood Abortion Form.

Not the Template you are looking for?
Request new template
Not the Template you are looking for?
Request new template

Questions for Planned Parenthood Abortion Form

1.

Patient Name

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Partner's Name

The answer should be a text input.
4.

Phone Number

The answer should be a phone number.
5.

Address

The answer should be a text input.
6.

Name of Doctor/Gynecologist

The answer should be a text input.
7.

Doctor/Gynecologist's Number

The answer should be a text input.
8.

Hospital Name

The answer should be a text input.
9.

Hospital Address

The answer should be a text input.
10.

How long have you been considering abortion?

The answer should be a text input.
11.

Why do you feel abortion is the best decision for you at this time?

The answer should be a text input.
12.

Reason for abortion.

The answer should be a single choice:
  1. Not financially prepared
  2. Bad timing, not ready, or unplanned
  3. Interferes with educational or job plans
  4. Partner-related reasons
  5. Health-related reasons
  6. Not emotionally or mentally prepared
13.

Please Specify your reason for abortion.

The answer should be a text input.
14.

What are your thoughts and feelings about the potential risks and complications of abortion?

The answer should be a text input.
15.

Have you discussed everything regrading your abortion procedure with your gynecologist?

The answer should be a single choice:
  1. Yes
  2. No
16.

Can you submit all the medical documents supporting your abortion reason.

File needs to be uploaded.
17.

Do you give your consent for abortion?

The answer should be a single choice:
  1. I agree
  2. I disagree
18.

Signature

The answer should be a signature.

Similar Ideas

  • Abortion Consultation Form
  • Abortion Services Agreement Form
  • Abortion Financial Responsibility Form
  • Parental/Guardian Consent Form

Here are some FAQs and additional information
on
Planned Parenthood Abortion Form

How often does abortion happen?

Abortion takes place in about 1 out of every 4 pregnancies.

What is the Planned Parenthood abortion form?

The Planned Parenthood abortion form is a medical form that must be completed by anyone seeking an abortion at a Planned Parenthood facility. The form must be signed by both the patient and the physician.

What information is required on the Planned Parenthood abortion form?

The form requires basic information about the patient, including their name, address, and date of birth. The form also requires information about the abortion procedure, including the type of procedure, the date of the procedure, and the name of the physician.

Why is the Planned Parenthood abortion form necessary?

The Planned Parenthood abortion form is necessary in order to ensure that the patient is fully informed about the risks and benefits of the procedure. The form also ensures that the physician performing the procedure is properly trained and qualified.

Want to use this template?

Loved by people at home
and at work

“BlockSurvey is a simple, effective, and scalable tool for creating surveys for leadership and learning assessment. It's one of this year's best buying choices. Each month, it keeps improving and strives to serve its customers needs.”
Nelson Emilio
Personal Branding Strategist
“I use BlockSurvey to get feedback about all my activities and events. It is really easy to get started and create my first surveys! Then I could see how easy it was to share them. Now I am thinking to use BlockSurvey also within my creative process as an author in order to listen and engage with my audience, knowing that anonymity provides the most sincere and reliable answers.”
Georgina García-Mauriño
Author & Designer
BlockSurvey social proof
G2 Crowd
4.8 Star Rating
BlockSurvey social proof
Dapp.com
Editor's choice
BlockSurvey social proof
Capterra
4.9 Star Rating

What's next? Try out templates like
Planned Parenthood Abortion Form

1000+ Templates, 50+ Integrations

Want to create secure online forms and surveys?

Join BlockSurvey.

SHARE