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Home › Consent to medical termination of pregnancy

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Consent to medical termination of pregnancy

Name(Required)

First name Last name

Date of Birth(Required)

Email address(Required)

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Before proceeding with medical termination of pregnancy using please read the following information carefully and click each checkbox to indicate you have understood and agree with the information provided to you.
Any specific concerns should be discussed with your doctor prior to submitting the consent form.

Consented:(Required)

I understand that I have been prescribed medications used to end a pregnancy.

Consented:(Required)

I have been provided with clear instructions on how and when to take the medications and have received written information about the treatment and aftercare.

Consented:(Required)

The nature and risks of this treatment have been explained to me, as well as alternatives, including surgical termination and not proceeding with treatment (continuing the pregnancy)

Consented:(Required)

Possible side effects of this treatment include, but are not limited to, heavy or prolonged bleeding, severe cramping which is not relieved by pain medication, nausea, vomiting, diarrhoea, dizziness, headache, fever and chills.

Consented:(Required)

I understand that complications may occur or the expected result may not be achieved, even though the treatment is provided with professional care.

Consented:(Required)

There is around a 1% (1 in 100) chance that this treatment will fail to end the pregnancy. If this happens, or if the treatment is not completed after it has begun, there is a risk the medications may harm the fetus if the pregnancy continues. Surgical termination or a repeat medical termination is strongly recommended. If surgical treatment is required, there may be an additional cost.

Consented:(Required)

There is up to a 4% (4 in 100) chance of incomplete abortion (retained pregnancy tissue or clot) which may require surgery or more medication. There may be an additional cost for this if further treatment is required.

Consented:(Required)

There is a 1-2% (1-2 in 100) chance of heavy bleeding (haemorrhage) requiring surgical treatment, and a 0.1-0.2% (1-2 in 1,000) risk of requiring a blood transfusion.

Consented:(Required)

There is less than 1% (1 in 100) chance of an infection occurring. Although serious infections are very rare in a medical termination of pregnancy, they can be potentially life threatening.

Consented:(Required)

I have discussed and understand how I will access emergency care, if it is needed.

Consented:(Required)

I agree to perform a follow-up self-assessment in 14 to 21 days, including a urine pregnancy test, to exclude the possibility of an ongoing pregnancy and other possible complications. I will contact the aftercare service or seek medical advice if I have any concerns.

Consented:(Required)

I agree to comply with follow up arrangements, as advised by staff, which may include further tests or investigations, or review at a clinic or hospital, or with a general practitioner.

Consented:(Required)

I understand that any ultrasound, if performed, was only used to confirm and date my pregnancy.

Consented:(Required)

I agree for my medical record to be accessed by staff involved in my clinical care and for it to be used for approved quality assurance activities, audit and research in a deidentified format, and in accordance with reporting requirements and privacy legislation.

Consented:(Required)

I understand that I have the right to change my mind at any time before the treatment has started, including after I have signed this form. I understand that I must inform my doctor if this occurs.

By clicking submit I confirm that I have read and understood the information above. The treatment has been explained to me in language I understand. I have had the opportunity to ask questions and I am satisfied with the answers given. I consent to medical termination of pregnancy.

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​Consent to medical termination of pregnancy

Consent to medical termination of pregnancy