| If you would like to reduce the
amount of time spent at your appointment, please download the appropriate
forms, print, complete and bring them with you.
NOTE: The following forms are made available to you online
in Adobe Reader. Please access www.adobe.com
for a free download.
| » |
Medical
History [pdf] |
| » |
Ultrasound
Consent [pdf] |
| » |
Surgical
Abortion Informed Consent [pdf] |
| » |
Medical
Abortion (Abortion by Pill) Informed Consent (Must be less than
9 weeks from last menstrual period) [pdf] |
| » |
Abortion
Questionnaire [pdf] |
| » |
Parental
Consent Form (Under the age of 18) [pdf] |
| |
* If you feel you are unable to tell your
parent or legal guardian, you will need a judicial bypass. Please
call our office for assistance.
Please
note: The State of Tennessee requires the consent
of one parent for a minor patient (under 18 years of age). KCRH
must document that we have obtained consent. To do so, all the
following requirements must be met:
1) The minor patient’s parent or legal guardian must accompany
the patient to her appointment.
2) Photo identification of the parent or legal guardian must
be brought to the appointment.
3) Identification of the minor patient (preferably photo) must
be brought to the appointment.
4) The patient’s birth certificate with the parent listed
on it. If a legal guardian, the court papers showing guardianship
must be brought to the appointment.
5) If the names have changed since the paperwork was issued,
whatever legal paperwork exists to show the name changes from
past to current must also be brought to the appointment (i.e.
marriage licenses, adoption papers, etc.)
Please call if you have questions; the staff will be happy to
help. |
|
