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Termination of Pregnancy Form

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Early Medical Abortion (EMA) Consent Form

Please read this form carefully. If your treatment has been planned in advance, you should already have a copy of the patient information leaflet which describes the benefits and risks of the proposed treatment. If not, you will be given a copy now. If you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form.

I agree to the procedure or course of treatment described on this form.

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.

I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia).

I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.

I understand that any tissue samples arising from a pregnancy will be treated with dignity and respect, and will be processed separately from other samples. The hospital will arrange for the tissue to be packaged and sent for communal cremation at Penmount Crematorium.

I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion.

I have received a copy of the Consent Form and Patient Information leaflet: Your medical procedure (EMA) CHA3277 which forms part of this document.

NHS number:

Name of patient:

Address:

Date of birth:

CR number:

STATEMENT OF HEALTH PROFESSIONAL

I have explained the procedure to the patient. In particular, I have explained that the patient will need to:

• Take a mifepristone tablet at the hospital

• Return to the hospital after one or two days for a vaginal pessary (misoprostol) and then to return home where the abortion is expected to occur after 1-4 hours

• Perform a pregnancy test after two to three weeks and to have a follow up consultation to ensure that the abortion is complete. This may be in clinic or on the telephone

Significant, unavoidable or frequently occurring risks:

• Having an abortion is safer than continuing with a pregnancy, but all procedures carry some risk

• Bleeding, similar to a heavy period. Rarely, this can require a blood transfusion or further surgery

• Infection despite preventative antibiotics that are routinely used (eg tablets and suppositories)

• An operation under general or local anaesthetic to empty the womb may be necessary because of heavy bleeding or continuing pregnancy

Uncommon but more serious risks:

• Pregnancy continuing despite treatment. This risk is increased if there is failure to complete the treatment, or to have a pregnancy test and follow up consultation. If the pregnancy does continue, there may be a small risk of abnormal development of the baby.

Any extra procedures which may become necessary:

• Laparoscopy (telescope through abdominal wall) or laparotomy (open abdominal surgery) is very rarely required following serious complications

I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.

I have given and discussed the Trust’s approved patient information leaflet for this procedure: Your medical procedure CHA3277 which forms part of this document.

I am satisfied that this patient has the capacity to consent to the procedure.

This procedure will involve:

Health Professional signature:

Date:

Name (PRINT):

Job title:

STATEMENT OF INTERPRETER (where appropriate)

I have interpreted the information above to the patient to the best of my ability and in a way in which I believe he/she can understand.

Interpreter signature:

Name (PRINT):

Date:

STATEMENT OF PATIENT

Please read this form carefully. If your treatment has been planned in advance, you should already have a copy of the patient information leaflet which describes the benefits and risks of the proposed treatment. If not, you will be given a copy now. If you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form.

I agree to the procedure or course of treatment described on this form.

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.

I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia).

I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.

I understand that any tissue samples arising from a pregnancy will be treated with dignity and respect, and will be processed separately from other samples. The hospital will arrange for the tissue to be packaged and sent for communal cremation at Penmount Crematorium.

I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion.

I have received a copy of the Consent Form and Patient Information leaflet: Your medical procedure (EMA) CHA3277 which forms part of this document.

Patient signature:

Name (PRINT):

Date:

A witness should sign below if this patient is unable to sign but has indicated his or her consent. Young people / children may also like a parent to sign here (see guidance notes).

Witness signature:

Name (PRINT):

Date:

CONFIRMATION OF CONSENT (to be completed by health professional when the patient is admitted for the procedure, if the patient has signed the form in advance).

On behalf of the team treating the patient, I have confirmed with the patient that they have no further questions and wish the procedure to go ahead.

Health Professional signature:

Date:

Name (PRINT):

Job title:

Important notes (tick if applicable):

Patient signature:

Name (PRINT):

Date:

The following details may be completed for the procedure record:

Procedure name:

Additional procedures required:

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What the Termination of Pregnancy Form Is and When it Applies

A Termination of Pregnancy Form is a medical-legal record documenting a patient's informed consent to an abortion or pregnancy termination procedure. It records patient identification, clinical information (including gestational age and relevant findings), an explanation of risks and alternatives, the provider's assessment and attestation, and signatures from the patient and clinical staff. In the United States this form is part clinical chart and part legal consent; properly completed forms become part of the permanent medical record and may be subject to state reporting or documentation rules.

Why a Complete, Accurate Form Matters

A properly completed Termination of Pregnancy Form documents informed consent, supports clinical decision-making, protects patient rights, and reduces legal and regulatory exposure. Accuracy also ensures correct billing, continuity of care, and reliable medical recordkeeping.

Why a Complete, Accurate Form Matters

Who Completes and Relies on This Form

Accurate completion matters for clinical care, insurance processing, quality review, and any state-mandated reporting; keep copies in the medical record and provide the patient with a copy when required.

  • Patients and authorized representatives — sign consent and acknowledge risks in writing.
  • Clinicians (physicians, APRNs) — document medical indication, gestational age, and attestation.
  • Clinic administrators and medical records teams — file, retain, and produce records for compliance.

Step-by-Step: Completing the Form Correctly

Follow a consistent sequence to ensure clinical, legal, and administrative requirements are met before the procedure.

  • 01
    Verify Identity: Confirm patient identity with government ID and match to MRN.
  • 02
    Review Clinical Info: Record gestational age, exam findings, and any required labs or imaging.
  • 03
    Conduct Consent Discussion: Explain risks, benefits, and alternatives; document that the patient had opportunity to ask questions.
  • 04
    Sign and File: Obtain signatures, date the form, and file in the medical record immediately.

Configure an Online Workflow for Electronic Completion

Key settings ensure correct routing, authentication, and retention when the form is completed electronically.

Field Configuration
Authentication Level Email + SMS code recommended; KBA if required
Conditional Fields Show follow-up fields based on patient answers
Template Use Create a locked template to prevent text changes
Audit Trail Enable detailed logs and timestamp retention

Technical Requirements for eSigning and eSubmission

Integration with EHR systems, secure storage, and a tamper-evident audit trail reduce risk and simplify record retrieval for care and compliance.

  • File Formats: PDF or PDF/A preferred for medical records
  • Authentication: Support email, SMS OTP, and stronger options
  • Integrations: EHR and cloud storage integrations required

Typical Flow: From Consent Conversation to Filing

A predictable process improves patient experience and ensures records meet clinical and legal standards.

  • Prepare Document: Clinician or admin loads the approved form into the workflow.
  • Execute Consent: Patient reviews and signs electronically or on paper at point of care.
  • Provider Attestation: Clinician signs to confirm medical assessment and counseling.
  • Record Retention: Signed form saved in the EHR and retained per policy.

Essential Data Fields to Capture

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
MRN: Medical record number
Procedure Date: Date of consent/procedure
Gestational Age: Weeks and days
Provider Info: Name and license number

Common Preparation Errors to Avoid

  • Using nonstandard consent language or omitting required risk disclosures can create legal uncertainty.
  • Recording incorrect gestational age or missing exam data may affect eligibility and clinical documentation.
  • Leaving signature blocks unsigned or dated incorrectly risks consent being deemed invalid.
  • Failing to store the signed form in the medical record or to capture an audit trail complicates audits.

Consequences of Incomplete or Incorrect Forms

Invalid Consent: May expose provider to civil liability
Regulatory Penalty: State agencies may assess fines
HIPAA Violation: Unauthorized disclosures risk penalties
Criminal Exposure: Failure to follow statutory rules can trigger criminal review
Insurance Denial: Payors may deny claims for missing documentation
Quality Review Findings: Accrediting bodies can cite recordkeeping failures

Timing and Key Documentation Deadlines

Timely completion and filing reduce clinical risk; some actions must occur on the same day as consent or procedure.

Consent Timing:

Obtain and sign consent before the procedure begins

Provider Attestation:

Document clinician assessment on the procedure date

Copy to Patient:

Provide patient with a copy at discharge or on request

State Reporting:

File reports only where state law requires and within required timeframes

Record Filing:

Save completed form in the EHR immediately

Realistic Use Cases and Workflows

Two common scenarios illustrate how clinics and telehealth services use the form to document informed consent.

Clinic In-Person Workflow

A patient arrives for consultation and receives a counseling session

  • clinician documents gestational age and discusses options
  • the patient signs the consent form in the clinic; the signed original is scanned and retained in the EHR for follow-up and billing.

Telehealth and Remote Consent

Patient consults via secure telehealth platform and reviews consent text electronically

  • identity is verified via government ID and SMS code
  • the patient signs with an eSignature and the signed PDF with audit trail is stored in the EHR.

eSignature Pricing and Feature Snapshot for Managing Consent Forms

Compare common eSignature vendors by starting price and key features relevant to clinical consent workflows; signNow appears first as the initial vendor column.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Common Questions about Using and Signing the Form

Answers to frequent questions about validity, witnesses, corrections, electronic signatures, and recordkeeping.


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