Patient Identification Number: 7018
You have the right to information about your health condition and the following risks and hazards that may occur in connection with your planned care. Please read and initial the following blanks to indicate your voluntary and informed consent to proceed with the medical and/or surgical procedure:
_____ I understand that the physical risks associated with the procedure include, but are not limited to, menstrual-like cramping, infection, allergic reaction to other people’s babies, uterine perforation, increased alcohol consumption, sterility, hemorrhage, death, and/or possible continuation of the pregnancy.
