Abortion Form

The Abortion Form is used by healthcare providers to document the care and treatment of a patient who has had an abortion. The form usually includes the patient's demographics, medical history, and the type of abortion procedure that was performed.

Time to complete

3 minutes

Eligibility

Any women who is pregnant and is willing to do abortion, can fill this form.

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Questions for Abortion Form

1.

Full 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.

Hospital Name

The answer should be a text input.
8.

Hospital Address

The answer should be a text input.
9.

Number of weeks pregnant

The answer should be a number input.
10.

Reason for wanting an 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.
11.

Please Specify your reason for abortion.

The answer should be a text input.
12.

Have you had an abortion before?

The answer should be a single choice:
  1. Yes
  2. No
13.

How do you feel about your decision?

The answer should be a text input.
14.

Do you give your consent for abortion?

The answer should be a single choice:
  1. I agree
  2. I disagree
15.

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

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

Signature

The answer should be a signature.

Similar Ideas

  • Abortion Consent Form
  • Abortion Patient Information Form
  • Abortion Procedure Consent Form
  • Abortion Financial Responsibility Form
  • Pre-Abortion Counseling Form
  • Post-Abortion Counseling Form

Here are some FAQs and additional information
on
Abortion Form

How do I know if I am eligible for an abortion?

The first step is to schedule an appointment with one of our counselors. During your appointment, our counselors will review your medical history and current health to determine if you are eligible for an abortion.

What is the difference between an in-clinic abortion and a medication abortion?

In-clinic abortions are performed in our facility. Medication abortions are performed using medication that is taken at home.

What is the difference between a surgical abortion and a medication abortion?

Surgical abortions are performed in our facility. Medication abortions are performed using medication that is taken at home.

How much does an abortion cost?

The cost of an abortion depends on many factors, including the type of abortion, the gestational age of the pregnancy, and the location of the procedure.

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