PRINT OUT, FILL IN ALL INFORMATION, AND BRING IN WITH YOU Back to Main PROOF OF COMPLIANCE WITH 24 HOUR WAITING PERIOD I, _____________________________ , state that at least 24 hours before this abortion will be performed, a physician has orally informed me of: what an abortion is and how the abortion will be performed, as well as the risks and alternatives to an abortion. the probable gestational age of the fetus at the time of the abortion procedure. the medical risks of carrying the pregnancy to term. I am satisfied with the information provided by the physician. I further state that at least 24 hours before the abortion I was informed by a health care worker delegated by the physician that: The state publishes materials which describe developmental stages of the fetus. They also list agencies which offer alternatives to abortion. I have the right to review and/or receive these printed materials free of charge.       chose not to receive the materials.       asked for and received a copy of the materials. Medical assistance benefits may be available for prenatal, childbirth and neonatal care and that more information about this is contained in the printed materials published by the state. I understand that if this pregnancy is carried to term, the father is responsible to assist in the support of the child even if he has offered to pay for the abortion. I received this information on (Date):__________________ at __________am/pm. Patient Signature: __________________________________________________ Witness: _________________________________________________________ Date: ___________________________________________________________ Parent Signature: __________________________________________________ (if patient is less than 18 years of age) Physician Signature: ________________________________________________

© 2000 Allentown Women's Center, Inc.