PATIENT AGREEMENT

Mifeprex (mifepristone) Tablets

1. I have read the attached Medication Guide for using Mifeprex and misoprostol to end my pregnancy.
2. I discussed the information with my health care provider (provider).
3. My provider answered all my questions and told me about the risks and benefits of using Mifeprex and misoprostol to end my pregnancy.
4. I believe I am no more than 49 days (7 weeks) pregnant.
5. I understand that I will take Mifeprex in my provider's office (Day 1).
6. I understand that I will take misoprostol in my provider's office two days after I take Mifeprex (Day 3).
7. My provider gave me advice on what to do if I develop heavy bleeding or need emergency care due to the treatment.
8. Bleeding and cramping do not mean that my pregnancy has ended. Therefore, I must return to my provider's office in about 2 weeks (about Day 14) after I take Mifeprex to be sure that my pregnancy has ended and that I am well.
9. I know that, in some cases, the treatment will not work. This happens in about 5 to 8 women out of 100 who use this treatment.
10. I understand that if my pregnancy continues after any part of the treatment, there is a chance that there may be birth defects. If my pregnancy continues after treatment with Mifeprex and misoprostol, I will talk with my provider about my choices, which may include a surgical procedure to end my pregnancy.
11. I understand that if the medicines I take do not end my pregnancy and I decide to have a surgical procedure to end my pregnancy, or if I need a surgical procedure to stop bleeding, my provider will do the procedure or refer me to another provider who will. I have that provider's name, address and phone number.
12. I have my provider's name, address and phone number and know that I can call if I have any questions or concerns.
13. I have decided to take Mifeprex and misoprostol to end my pregnancy and will follow my provider's advice about when to take each drug and what to do in an emergency.
14. I will do the following:
    • Contact my provider right away if in the days after treatment I have a fever of 100.4°F or higher that lasts for more than 4 hours or severe abdominal pain.
    • Contact my provider right away if I have heavy bleeding (soaking through two thick full-size sanitary pads per hour for two consecutive hours).
    • Contact my provider right away if I have abdominal pain or discomfort, or I am “feeling sick”, including weakness, nausea, vomiting or diarrhea, more than 24 hours after taking misoprostol.
    • Take the MEDICATION GUIDE with me when I visit an emergency room or a provider who did not give me Mifeprex, so that they will understand that I am having a medical abortion with Mifeprex.
    • Return to my provider’s office in 2 days (Day 3) to check if my pregnancy has ended. My provider will give me misoprostol if I am still pregnant.
    • Return to my provider’s office about 14 days after beginning treatment to be sure that my pregnancy has ended and that I am well.

Patient Signature: ___________________________________________

Patient Name (print): ________________________________________

Date: _____________________________________________________

The patient signed the Patient Agreement in my presence after I counseled her and answered all her questions. I have given her the Medication Guide for mifepristone.

Provider's Signature: ________________________________________

Name of Provider (print): ______________________________________

 

Date: _____________________________________________________

After the patient and the provider sign this Patient Agreement, give 1 copy to the patient before she leaves the office and put 1 copy in her medical record. Give a copy of the Medication Guide to the patient.

Rev 2: 7/19/05

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