PLEASE NOTE: If you have printing capabilities, please print this document and bring it with you to your appointment. If you are not able to print, we will provide you with an original when you arrive for your appointment.

Dear Prospective Patient:

I am Dr. George Tiller, a 1967 graduate of the University of Kansas School of Medicine, a diplomat of the American Board of Family Practice. My medical practice has included legal and safe abortion services for thousands of women since 1973.

The 1997 Kansas abortion law requires that I provide certain written information to patients seeking abortion services at least twenty-four hours before an abortion is performed. This document will satisfy the basic notification requirement.

1. I or my associates, Dr. Leroy Carhart, Dr. Shelley Sella or Dr. Susan Robinson will perform your procedure. (See our calendars (this month - next month) for doctor on duty for your date). As Medical Director, I am the supervising physician responsible for your care. You will meet with Dr. Carhart, Dr. Sella, Dr. Robinson or me prior to your surgery.
2. Based on the first date of your last menstrual period or an ultrasound evaluation, the gestation of your pregnancy is estimated to be________ plus or minus 11 to 14 days (PLEASE INSERT GESTATIONAL AGE FROM "HOW FAR ALONG IS YOUR PREGNANCY").
3. Generally speaking, complications associated with full term childbirth occur more frequently and are more serious that those associated with abortion. Possible childbirth complications include operative delivery, allergic reactions to anesthetics or other medications, bleeding, blood clots, and high blood pressure. For additional information about risks associated with continuing a pregnancy see attachment A.
4. The methods of abortion available at Women's Health Care Services are

   Non Surgical - up to 8 weeks from last menstrual period

   Vacuum Aspiration - 5-14 weeks from last menstrual period

   Dilatation and Extraction - 15 weeks or more from last menstrual period

   Digoxin Induction - 22 weeks or more from last menstrual period
   If you care to read more about the above procedures see attachment B.
   

5. The risks of an abortion are related to the duration of the pregnancy and the health of the pregnant woman. Generally speaking, an abortion performed early in a pregnancy is safer than one performed later in the pregnancy. Possible abortion complications include allergic reactions to anesthetics or other medications, bleeding, infection, laceration, and perforation. For additional information about risks associated with abortion see attachment C.
6. A woman with Rh negative blood will be given an injection of immune globulin to prevent blood incompatibility problems in future pregnancies. Cost for this injection in our office is $50 if you are 5-14 weeks pregnant and $100 if you are 14 weeks and up.
7. The 1997 Kansas abortion law defines pregnancy as the existence of a fetus in the woman's body. Detailed information about the probable anatomical and physiological development of a normal pregnancy can be found in attachment D.
8. Medical assistance benefits may be available for prenatal care, childbirth and neonatal care. County Health Departments provide a variety of services. Private physician care is listed in the Yellow pages under "Physicians - Gynecology" and "Physicians - Obstetrics". Or you may contact the Kansas Department of Health and Environment for referral assistance.
9. If you decide to continue the pregnancy the male involved in the pregnancy is liable to assist in the support of the child.
10. You are free to withhold or withdraw your consent to the abortion at any time prior to invasion of the uterus without affecting your right to future care or treatment and without the loss of any state or federally-funded benefits to which you might otherwise be entitled.
11. No person shall perform or induce an abortion when the fetus is viable unless such person is a physician and has a documented referral from another physician not legally or financially affiliated with the physician performing or inducing the abortion and both physicians determine that: (1) the abortion is necessary to preserve the life of the pregnant women; or (2) a continuation of the pregnancy will cause substantial and irreversible impairment of a major bodily function of the pregnant woman.
12. No person shall perform or induce a partial birth abortion when the fetus is viable unless such person is a physician and has a documented referral from another physician not legally or financially affiliated with the physician performing or inducing the abortion and both physicians determine that: (1) the abortion is necessary to preserve the life of the pregnant women; or (2) a continuation of the pregnancy will cause substantial and irreversible impairment of a major bodily function of the pregnant woman.

     

By signing below, you acknowledge that you have read and understood the information above, and that you have received this information twenty-four hours prior to your abortion.

SIGNATURE:_________________________

Attachment A | Attachment B | Attachment C | Attachment D