3 101 RICHMOND A VENUE, SUITE 250
HOUSTON. TEXAS 77098
FAX (713) 526-0598
!, ____________ (patient), declare in the presence of Adebayo
Adesomo MD, that on this date __________ ,! am not over 70
days
pregnant. I am consenting to have the FDA approved protocol for
administration of
RU-486, for chemical abortion.
________________ (signature of patient)
___________ (date patient signed)
(signature of physician) ----------------
__________ ( date physician signed)
Surburban Women's Family Planning Clinic 3101 Richmond, Suite 250
Houston, Texa 77098
Phone 713-526-6.500 ·
Name _______________________ Date _______ _
Town/Village-------.-------- State ________ County _____ _
1,-----------------------, am ________ years old, and I request and
consent to the oerformance upon me of a pregnancy termination
orocedure (abortion) at Suburban Women's Family Planning Clinic by
Dr. Adebayo J. Adesomo or
Dr.-----------------------------
jtype or writ• in 1ha name of a phy1ici1n who will do 1he procedure
01her than thoae linadl
I also consent that said doctor may preceding, during, and
following the operation perform any other procedure or reasonably
indicated tests, which he deems necessary o desirable in order to
per• form the abortion, or correct any other unhealthy conditions
he may encounter whether or not re iated to the presently known
condition. If any unforseen event occurs during the abortion, I
further request and authorize the doctor to. do whatever he may
deem advisable or necessary to protect my health, life or welfare,
using his professional judgment.
I have fully and completely disclosed my medical histories,
including allergies, blood conditions, prior medications or drugs
taken;-and reactions that I have had to anesthetics, medicines, and
other drugs .. I understand that the physician treating me is
relying upon th' honest and complete dis closures which I have
made with regard to such information.
I consent that the physician or hs associates may administer
anesthesia and medic.ations as may be deemed necessary or
advisable. l unBerst-and -that local anesthetics do not always
eliminate all pain, that in a few cases local anesthetics may cause
severe reactions, and even shock. and that no guarantee: or
statement to the contrary have been made to me.
I realize that my ebonion req·uires the cooperation of technidans,
assistants, nurses and other per!!lnnel; therefore, I give my
fQrther consent to the administration of medications on my body by
all such qualified medical personnel working under the supervision
of a Doctor before, dur· ing and after this operation.
! understand that the complica.tions associated with pregnancy
termination are generally much less severe than with childbirth.
Nonetheless, I realize there are risks of complications .{both
minor 11nd major) which may occur in this 1urgical procedure,
without tlie fault of the physician. No guar• antees have been made
to me that I will not suffer a complication. I understand the
posibility of perforatlo,, of the uterus and .Internal injuries
resulting therefrom. I understand the possibility that not all of
the tissue will be removed, that fever may occur, that bleeding may
occur during or after tha procedure, that infection may occur, and
that I may react badly to medicines or the anesthesia; that I may
h!ve pain, cramps or even convulsions, and that I may have mild or
severe reactions to any of the contraceptives which I use
later.
I am aware after reading the attached fact sheet and from the
explanation I have received, of th, risk1 involved in an abonion
and possible complications. I understand that any questions I
ha.,.e wm b'e answered by my physician'and/or counselor, and that I
may ask such questions before leav
.ing the office. lf I have questions or complic·ations·after
leaving the office, I agree to call the physi cian or oftie at
713-526-6500 immediately.
I understand that the abortioh procedure is not fully completed
until I have a follow-up check up (this theck up must be before my
first menstrual period ·following the procedure) by either my
ohvsician er a aualified desionated clinician.
I understand that tissue and/or fetal parts will be removed during
the procedure1 and mr.i I con
sent to their examination and disposal' by the technician and/or
physician in the manner that the)f deem appropriate. t" k,:'IOW
that the practice of medicine in surgery is not an exact science;
therefore, reputable practitioners cannot guarantee results. I
acknowledge ttiat no.'guarantee or assurances have been made to me
by anyone regarding the operation that I have herein requested and
authorized, ano furthermore, I understand that when possible, I may
be treated for any resulting comp1icat1011 ?St the office at no
charge to me; however, should. hospitalization be necessary, I
understand that I will ue responsible for any and all charges
therein.
I agree thatany dispute or claim which I may have re la.ting to the
a_bortion, or any related medi cal procedure, or any of the medical
personnel performing said. abortion Qr related procedure, shall be
dtermined solely by a decision under the protection and protocols
a.s set forth by the American Arbitration Association.
I cenify that I have read and fullv. understand the above consent
to an abortion and the agree ment to arbitration, and that all of
the above blanks or statements requiring completion are filled in,
and that the information placed therein is true and correct to the
best of my personal knowledge. I fully under5tand that the purpose
of this procedure is to end my pregnancy and I affirm this to be my
per·sonal choice. I know pr have had an explanation of other
alternatives such as continuing my pregnancy to term. No one has
coerced or compelled me to make this decision.
Date: Patient's signature
Dilution ond curottogo of ulorus (obstotrlcol)
1. Hemorrhage wllh poss!ble hysturoctomy lo control 2. Porforallon
ol tho uterus. 3. Storllity.
Witness/Counselor 4. Injury to bowel and/or bladder. 5. Abdomlnnl
Incision and operation lo correcl injury. 6. Failure to removo all
products of conception.
09-5572 R 1/88
If in the opinion of a physician, hospitalization is required, t
hereby ·give my consent to be transferred to a hospital.
Oate: Patient's signature
V{itness/Coun&elor
Name of Patient: -------------------------------------
r o THE PATIENT! You /Jave Iha right, es (1 pa!lenr, Co be Informed
by your phystG/anfpraorwoner aoour your condiUon and /110
recommendgd surgical, mad/cal, or dlagnosllc proGodure ro be used
so tflat you may maks the decision whether or not to undergo I/re
procapure af!er lcnowing the rls/cs and hazards Involved. This
disclosure Is not meant lo scare or alarm you: Jt Is simply an
effort to make you better Informed so you may give or wllhho/d your
consent to Cha procedure. ·
· Ad9bAyo J Adesomo, MD, FAOOG 1. I voluntarily raquesl Dr. ·
ae my physician, and such associates, technical assistants and
other health care providers as they may deem necessary, lo treat my
condition which has been eicplelned to me as: ____________
-:--------------------------------
VOLUNTARY TERMINATON OF PREGNANCY (INTRAUTERINE)
2. I understand that the follQwlng surgical, medical, and/or
diagnostic procedures are planned for me, and I voluntarily consent
and authorize lhm:e
procedures:-------------------------------,--------
(ABORTION)
DILATION & CURETTAGE OF UTERUS WITH SUCTION ( D C WITH SUCTION
.)
3, I understand that my physician may discover other or dlllerent
conditions that require addll!onal or dlllerent procedures than
those planned. I authorize my !)hyslclan and other health care
providers lo perform such other procadures as ara advisable In
their prolasslonal Judgment.
4. I (do) (do not) coneunt lo the use of blood and blood producta
as deemed nocessan,. -""C"".,-- •
PT, INITIAlS
5. Any tissues or parts surgically removed may be retained or
disposed of by The Msthodlst Hospital In accordance with Its
accustomed praotlce.
6. I understand that no warranty or guarantee hes been made to me
as to result or cure.
7. Just as there may be rlsl<S and hazards In continuing my
present condition without treatment, there are also rlsl1s and
hai:arcls related to tha perlormnnca of the surgical, medical,
and/or diagnostic procedures planned for me. I realize that, common
lo surgical, medical, and/or diagnostic procedures ls the polentlal
for Infection, blood clots In veins and lungs, hemorrhage; allerglc
reacllons, and even death. I olso realize that the risks am:!
hazards I ln\Ual on later pages of this form, and the following
rlsl<s and hezardo may occur ln connecllon with this parllcular
procedure:
OTHER/ADDITIONAL RISKS: CARDIOPULMONARY ARREST NECESSITATING CPR.
FATLED ABORTION CONTINUATION OF PREGNANCY.
o. I understand that onasthesla Involves additional risks and
hazards, but I requeet the use or anesthetics for the relief and
protocllon from pain during the planned and additional procedures.
I reallze Iha anesthesia may have to be changed, posslbly without
a><planatlon lo me.
9. I understand thnt certain compllcatlone may result from the use
of any anesthetic Including respiratory problems, drug raacllon,
paralysis, brain damage or even death, Other risks and hazards that
may result rrorn the use of general anesthetics range from minor
dlscomlorl to Injury to vocal cords, teeth or eyes. I understand
that olhei' risks and h02ards resulting from spinal or epidural
aneslheUcs Include headache and chronic pain. · ·
,::
·11. I certify this form has been fully explained lo me, that l
have read It or have had It read lo me, that the b!anl1 spaces have
been lilied In, and that I understand 11s contents,
Dale: ---:. ________ Time: _________ _ A,M. P,M,
Witness Name
ADEBAYO ,J. ADEBOMO . F.A.0,0.G. 3101J:UpHMOND, SUITE 250
HOUBjON, TX 77098 ·1,.
---
TEXAS DEPARTMENT OF STATE HEALTH SERVICES Sonogram and Abortion
Election Form
The information and printed materials described by Section l
71.012(aXl}-{3), Texas Health and Safety Code. have been provided
and explained to me. I understand the nature and consequences of an
abortion.
By initialing here, I certify that I am making this
decision/election of my own free will and without coercion.
Texas Law requires that I receive a sonogram prior to receiving an
abortion. I understand that I have the option to decline to view
the printed materials. l understand that I have the option to
decline to view
· the sonogram images. I understand that I have the option to
decline to hear the heartbeat. I understand that I am required
by•lew to hear an explanation of the sonograrn images unless I
certify in writing to one of the following:
Initial
I am pregnant as a result of a sexual assault, incest, or other
violation of
the Texas Penal Code that has been reported to law enforcement
authorities or that has not been reported because I reasonably
believe that doing so would put me at risk of retaliation resulting
in serious bodily injury.
I am a minor and obtaining an abortion in accordance with judicial'
bypass procedures wider Chapter 33, Texas Family Code.
My fetus has an irreversible medical condition or abnormality, as
identified by reliable diagnostic procedures and documented in my
medical file.
For a woman who lives I 00 miles or more from the nearest
abo1'tlo11 provider that Is a facility licensed under Chapter 245
or a facility that performs more than 50 ""'!rtlons·in any 12-month
period ONLY:
I certify that, because I currently live 100 miles or more from
tli«S-nearest abortion provider that is a facility licensed under
Chapter 245 or a facility that performs more than 50 abortions in
any 12-month period, I waive the requirement to wait 24 hours after
the sonogram is perfonned before receiving the abortion procedure
and understand that I must wait at least 2 homs after the sonogram
is performed before the abortion procedure.
My place of residence is: ______________________ _
Signature Date
3101 RICHMOND AVE., STE. 250 HOUSTON, TEXAS noss
Waiver for women who live 100 mU.S or more from the nearest
abortion provider
Place initials beside each statement and sign the bottom of the
form.
_ I certify that I currently live 100 miles or more from the
nearest licensed abortion provider or a facility that performs more
than 50 abortions in any 12-month period.
__ I certify that, at least 2 hours prior to tM abortion, a
sonogram was performed on me.
I certify that, at least 24 hours ptior to the abortion, the
physician who is to perform the abortioo informed me by telephone
or in person of:
__ the physician's name:
_ the particular medic;al risks associated with the particular
abortion procedure to be employed: including when medically
accurate:
_ the risk of infe«ion and hemorrhage; __ the potential danger to
subsequent pregnancy and of infertility; and _ the possibDlty of
increased risk of breast cancer foHowing an induced abortion and
the
natural protective effect of a completed pregnancy in avoiding
breast cancer.
__ the probable gestational age of the pregnancy at the time the
abortion is to be performed; and
_ the medical risks associated with carrying the pregnancy to
term.
I certify that, at least 24 hours prior to the abortion, the
physician who is to perform the abortion or the physician's agent
informed me by telephone or in person that:
__ medical assistance benefits may be available for prenatal care,
childbirth, and neonatal care:
the father is liable for assistance in the support of the child
without regard to whether the father -- has offered to pay for the
abortion;
. _ public and private agencies provide pregnancy prevention
counseling and medical referrals for obtaining pregnancy prevention
medications °' devices; and
__ printed materials prepared by the Texas Department of Health
entitled the ''A Woman·, Right to Know" booklet and the resource
directory, which describes fetal clevelopment and list agencies
that offer alternatives to abortion, are accessible on an Internet
website sponsored by the Department, that the materials include a
list of agencies that offer sonogram services at no cost to
me,.
== provided me with the website address, and
PLEASE CHOOSE ONE OF THE FOLLOWING __ provided me with tne printed
materials OR __ I certify that I chose to view those materials on
the Internet
Signature Date
Printed Name
Hl)use Bill 15 Information Fcbru.:try 6. 2012 Pagll J
A pregnant woman may choose not t<> view the printed
materials after she has been provided the mnterials.
r-1 • t ·-1 •
A pregnant woman may choose not to view the sonogram images.
A pregnant woman mny choose not to hear the heart
luscultation.
· A pregnant woman may choose not to receive the verbal explanation
of the results of the sonogram images only if she cer1ifies in
writing on the sonogram/abortion election form. one of the
following:
o the pregnancy is a result of a seual assault, incest, or other
violation of the Penal Code that has been reported to law
enforcement authorities or that has not been reported because she
reasonably believes that to do so would put her at risk of
retfliation resulting in serious bodily injury;
o the woman is a minor nnd obtaining an abortion in uccordance with
judicial bypass prncedures under Chapter 33, Family Code; or
o the ftus hm, an irreversibk medical condition or abnonnality, :is
medically documented in the woman's medicnl file.
In a medical emergeru:y, an ahorrion provider may perform an
abortiori without obtaining a sonogram and m11st:
• include in the patient's medical record a signed statement on the
medical emergency form, certifying the nature of the emergency;
and
• not later than 30 days after the <late of the aborfibn, submH
the medical emergency form to the Department. ·-·
• NOTE: The medical emergency fonn can be found and downloaded at
the following website as of the date of this letter:
http://www.ushs.st<lte.t x.us/htblapps.sb1m#abo11i{)Q.
Jftlupregnant woman decli11es to proceed with an abortion after
being provided with the information req11ired by law, then the
physician or agent of that physician must provide her with a state
publication with iriformatir,n "" paternity establishment and
child support ol>li_f{atlons.
A,, ,=,.,, ,I f'lnn11rrl, ,nil&, l=mnlnugr t:l,,..,.J
Or.1n,irlQ;
v a6ed