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PATIENT AGREEMENT FORM
Mifepristone Tablets, 200mg

Healthcare Providers: Counsel the patient on the risks of mifepristone. Both you and the patient must sign this form.

Patient Agreement:
1. I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my provider's advice about when to take each drug and what to do in an emergency.

2. I understand:
a. I will take mifepristone on Day 1.
b. My provider will either give me or prescribe for me the misoprostol tablets which I will take 24 to 48 hours after I take mifepristone.

3. My healthcare provider has talked with me about the risks including:
     • heavy bleeding
     • infection
     • ectopic pregnancy (a pregnancy outside the womb)

4. I will contact the clinic/office right away if in the days after treatment I have:
     • a fever of 100.4°F or higher that lasts for more than four hours
     • severe stomach area (abdominal) pain
     • heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)
     • stomach pain or discomfort, or I am "feeling sick", including weakness, nausea, vomiting, or diarrhea, more than 24 hours after taking misoprostol

5. My healthcare provider has told me that these symptoms could require emergency care. If I cannot reach the clinic or office right away my healthcare provider has told me who to call and what to do.

6. I should follow up with my healthcare provider about 7 to 14 days after I take mifepristone to be sure that my pregnancy has ended and that I am well.

7. I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use this treatment. If my pregnancy continues after treatment with mifepristone and
misoprostol, I will talk with my provider about a surgical procedure to end my pregnancy.

8. If I need a surgical procedure because the medicines did not end my pregnancy or to stop heavy bleeding, my healthcare provider has told me whether they will do the procedure or refer me to another healthcare provider who will.

9. I have the MEDICATION GUIDE for mifepristone. I will take it with me if I visit an emergency room or a healthcare provider who did not give me mifepristone so that they will understand that I am having a medical abortion with mifepristone.

10. My healthcare provider has answered all my questions.

Patient Signature:
*Please provide first and last name

The patient signed the PATIENT AGREEMENT in my presence after I counseled her and answered all her questions. I have given her the MEDICATION GUIDE for mifepristone.

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Timestamp

Audit

September 29, 2020 5:57 pm CDT

GBP consent Uploaded by Just The Pill - [email protected] IP 2601:448:c580:db0:11c0:5b6b:5b12:ce7e