24
Hour Notification
PATIENT NAME: ___________________________
Dear Prospective Patient:
I am A. Kristin Neuhaus, M.D., a 1985 graduate of the University of Kansas School of Medicine. I have been providing pregnancy termination as well as primary care medicine since 1986. Our clinic staff is very concerned about your safety and confidentiality. All the material you will need to read or complete is included in this internet site, to shorten your stay at the clinic.
Based on the date of the first day of your last menstrual period of __________________, you will be about ________ weeks pregnant by your appointment date on ___________________ at ___________. (You may be a month further if your last period was unusually light). Please note that the photographs in the booklet If You Are Pregnant are dated from the point of fertilization of the egg. The more conventional method of dating from last menstrual period (LMP) is listed beneath in parenthesis Our clinic uses this conventional dating, so if you are told you are 8 weeks LMP, the corresponding picture would be the one labeled "Week 6." Fees are based on weeks as dated by sonography (ultrasound).
OPTIONS - If you are pregnant, you have the following options: carry the pregnancy to term and raise a child, carry a pregnancy to term for purposes of adoption, or terminate the pregnancy up to 24 weeks. After 24 weeks a medical reason must exist for the pregnancy to be terminated.
DESCRIPTION OF PROCEDURE - the actual procedure usually takes 5 minutes or less. Following administration of twilight anesthesia and/or a local anesthetic around the cervix, a series of dilator rods, each a little wider than the one before, are used to open the cervix until it will permit the insertion of a tube into the uterus. Suction is then applied to the tube to empty the contents of the uterus. A loop shaed instrument called a curette is used to remove any remaining tissue.
ANESTHESIA - there are two options available
at our clinic:
Local anesthetic - allows a patient to come alone and driver herself home,
but provides a lower level of comfort.
Twilight Sleep - with this option, patients usually have no experience of
the procedure but generally do not wake up feeling ill as with general anesthetics.
This is the favored choice for most patients. You must have a support person
to drive you home.
COMPLICATIONS - Serious complications are rare. First trimester procedures carry a lower mortality rate than a penicillin injection. The most common complications are infection; a tear in the cervix, which may need to be repaired with stitches; excessive bleeding; an abortion that is not complete or in which blood clots accumulate in the uterus, requiring the proecedure to be repeated. Rare complications include medicine allergic reaction; perforation of the wall of the uterus and possibly other organs, which may require surgical repair; severe bleeding due to the failure of the uterus to contract, which may require a blood transfusion; first trimester abortion carries a mortaility rate of approximately 1 in 200,000 procedures.
RISKS ASSOCIATED WITH TERMINATING A PREGANCY COMPARED TO CARRYING TO TERM - Health risks are low with either decision. Death and serious complications with full term pregnancy are rare; first trimester abortion carries much lower risk than pregnancy.
STATEMENT: I RECEIVED THIS FORM AND THE TWO BOOKLETS: If You Are Pregnant ON _______________ , at _________ AM/PM. I will be at least 18 years of age on the day of my appointment.
Signature _______________________________________ Date _______________________
Fees are payable in cash or money order. No checks are accepted. Insurance accepted only with prior arrangement.
INSTRUCTION CHECKLIST:
