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Patient agreement

Cherry Hill Women’s Center
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. 3. My provider answered all my questions and told me about the risks and benefits of using Mifeprex and Misoprostol (Cytotec) to end my pregnancy. 4. I believe I am no more than 63 days (9 weeks) pregnant. 5. I understand that I will take a 200 mg dose of Mifeprex in my provider’s office (Day 1). 6. I understand I may take over the counter Non Drowsy Dramamine in the event I am nauseous following the Mifeprex and/or Misoprostol. 7. I understand I may take over the counter Non Drowsy Dramamine prior to taking the Misoprostol to decrease nausea and vomiting that may be caused by the Misoprostol. 8. I understand that I will be given 800 mcg of Misoprostol to take home with me. I will take this medication buccally, no sooner than 24 hours, and no later than 72 hours after I swallow the Mifeprex. 9. My provider gave me advice on what to do if I develop heavy bleeding or need emergency care due to the treatment. 10. 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. 11. 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. 12. 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. 13. 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. 14. I have my provider's name, address and phone number and know that I can call if I have any questions or concerns. 15. 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. 16. 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  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.  Take 800 mcg Misoprostol buccally, at home, 24-72 hours after I take Mifeprex.  Return to my provider’s office about 14 days after beginning treatment to be sure that my pregnancy has ended 17. I voluntarily request the Alternative Treatment plan for Medical Abortion using Mifeprex and Misoprostol from the
Cherry Hill Women’s Center.
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.
Witness Signature: ________________________________________
Date: _____________________________________________________
Rev 2: 3/8/08 * Mifeprex is a registered trademark of Danco Laboratories, LLC.

Source: http://www.cherryhillwomenscenter.com/wp-content/uploads/2012/03/CHWC-MAB-Patient-Agreement-Danco1.pdf

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