Disclosure and Consent for Medical, Surgical, and Diagnostic Procedures (Texas)

Planned Parenthood Corporate Office: 4600 Gulf Freeway Ste. 300, Houston, TX 77023 [713-522-6240]

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DISCLOSURE AND CONSENT FORM for MEDICAL, SURGICAL, AND DIAGNOSTIC PROCEDURES

PATIENT NAME: _________________________________DATE OF BIRTH: _______________ AGE: ____

This Form has been adopted by the Texas Medical Board in accordance with the requirements of §164.052(c),

Texas Occupations Code and is published in 22 Texas Administrative Code §165.6(f). The purpose of this Form

is to allow the physician to obtain the required consents for an abortion to be performed on an unemancipated

minor. This Form is available for downloading on the Texas Medical Board web site at “www.tmb.state.tx.us”.

Part I. Information about Patient Consent Requirements and Parental Consent

Requirements.

TO THE PATIENT: As the patient, you have the right to be given information about your health condition, our

plans for your care, and the risks and hazards of the planned care. You have the right to provide written

consent for the medical procedures agreed to be performed. As your physician, I am required by law to provide

this information to you, and to have your consent, or permission, before we can start any medical procedure on

you. This is called the “Patient Consent Requirement.” Your signature at the bottom of Part IV of this Form is

your consent for me to perform the medical procedures that are checked below in Part II.

TO THE PATIENT’S PARENT, LEGAL GUARDIAN, OR MANAGING CONSERVATOR: As the parent, legal guardian, or

managing conservator of a child, you have the right to be given information about your child or ward’s health

condition, our plans for her care, and the risks and hazards of the planned care. You are also required to

provide written consent, or permission, for the medical procedures agreed to be performed on your child or

ward, unless otherwise stated in law. This called the “Parental Consent Requirement”.

A child includes each patient who is under 18 years old, unmarried, and has not had the disabilities of minority

removed by court order. In Texas, this is called an “unemancipated minor.” I am required by law to have the

written consent of either one of the patient’s parents, legal guardian, or managing conservator before we can

perform an abortion on an unemancipated minor. The Parental Consent Requirement does not apply if the

unemancipated minor has a court order waiving the parental consent requirement (a “judicial bypass order”)

The Parental Consent Requirement has two parts. The first part requires one of the patient’s parents, legal

guardian, or managing conservator to initial each page of this Form. Their initials mean that they have had the

chance to read this information (or to have it read to them) and to ask questions. The initialing of each page

can be done at any time and at any location. The second part requires either one of the patient’s parents, legal

guardian, or managing conservator to sign the Parental Consent in Part V of this Form. This Form must be

signed in front of a person who is a notary public either in the physician’s office or clinic, or in front of a notary

public at any location. The purposes of these signing requirements are to help make sure that only those

persons listed on the Parental Consent in Part V of this Form are the ones who actually sign it.

Part II. Surgical and Medical Procedures.

The surgical and/or medical procedures that are planned to be performed on the patient are the ones that are

checked below. As used in this Form, “abortion” means the use of any means to terminate the pregnancy of a

female known by the attending physician to be pregnant with the intention that the termination of the

pregnancy by those means will, with reasonable likelihood, cause the death of the fetus.

 Dilatation and Curettage (D&C)  Dilatation and Evacuation (D&E)  Manual Vacuum Aspiration

 Machine Vacuum Aspiration

Medical Abortion Procedures:  Methotrexate  Misoprostol

Other as listed: _______________________________________________________________________________

Planned Parenthood Corporate Office: 4600 Gulf Freeway Ste. 300, Houston, TX 77023 [713-522-6240]

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Part III. Risks and Hazards.

There are risks and hazards related to the surgical and medical procedures planned for the patient. The

following list is not meant to scare the patient, but to give her and her parent, legal guardian, or managing

conservator adequate information to be used in making their decisions to have the physician perform the

particular procedures checked above.

The patient should read and initial the following blanks. Her initials mean she has read the information (or had

it read to her) and agrees with the statement.

_____ I have been told by the physician or physician’s assistant about the following risks and hazards that

may occur in connection with any surgical, medical, and/or diagnostic procedure:

(A) Potential for infection. (B) Blood clots in veins and lungs. (C) Hemorrhage.

(D) Allergic reactions. (E) Even death.

_____ I have been told by the physician or physician’s assistant about the followings risks and hazards that

may occur with a surgical abortion:

(A) Hemorrhage (heavy bleeding).

(B) A hole in the uterus (uterine perforation) or other damage to the uterus.

(E) A possible hysterectomy as a result of complication or injury during the procedure.

(F) Failure to remove all products of conception that may result in an additional procedure.

_____ I have been told by the physician or physician’s assistant about the followings risks and hazards that

may occur with a medical/non-surgical abortion:

(A) Hemorrhage (heavy bleeding).

(B) Failure to remove all products of conception that may result in an additional procedure.

_____ I have been told by the physician or physician’s assistant about the following risks and hazards that

may occur with this particular procedure:

(A) Cramping of the uterus or pelvic pain.

(B) Infection of the female organs: uterus, tubes, and ovaries.

(D) Emergency treatment for any of the above named complications.

(E) Other as written:

______ I have been told by the physician or physician’s assistant about the following other information that is

required by law to be discussed before I can give my voluntary and informed consent to an abortion:

(See §171.11 and §171.12, Texas Health and Safety Code):

(1) the probable gestational age of the fetus;

(2) the medical risks associated with carrying the child to term;

(3) medical assistance benefits may be available for prenatal care, childbirth, and neonatal care;

(4) the father is liable for assistance in the support of the child without regard to whether the father

has offered to pay for the abortion;

(5) public and private agencies provide pregnancy prevention counseling and media referrals for

obtaining pregnancy

medications or devices, including emergency contraception for victims of rape or incest; and

(6) the woman has the right to review the printed materials provided by the Department of State

Health Services.

Planned Parenthood Corporate Office: 4600 Gulf Freeway Ste. 300, Houston, TX 77023 [713-522-6240]

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Part IV. Patient’s Consent for Surgical or Medical Procedure

To meet the Patient Consent Requirement, the patient must complete Part IV of this Form. An initial on each

blank means that the patient has read (or had the information read to her) and agrees with the statement. The

patient’s signature means that she is agreeing to have the abortion procedures set out above.

Patient Consent Statement:

_____ I understand that my doctor __________________________________________________ (print the

name of your doctor) is going to perform an abortion on me, which will end my pregnancy and will

result in the death of the fetus.

_____ I understand that I am not being forced to have this abortion and have the choice on whether to have

this procedure.

_____ I give my permission to this doctor and such other associates, technical assistants, and other health

providers as the doctor thinks is needed to perform the abortion on me using the surgical and medical

procedures checked above.

_____ I understand that my physician may discover other or different conditions that require additional or

different procedures than those planned.

_____ I give my permission to my physician and such associates, technical assistants and other health care

providers to perform such other procedures that are advisable in their professional judgment.

_____ I do do not give my permission for the use of blood and blood products as deemed

necessary.

_____ I understand that my doctor cannot make any promise regarding the end results of the abortion or my

care.

_____ I understand that there are risks and hazards that could affect me if I have the surgical or medical

procedures checked above.

_____ I have been given an opportunity to ask questions about my condition, alternative forms of treatment,

risk of non-treatment, the procedures to be used, and the risks and hazards involved.

_____ I understand that information about abortion that is included in the law as the Woman’s Right to Know

Act has been made available to me as required by §171.001, et seq., Texas Health and Safety Code,

specifically the “Women’s Right to Know Informational Brochure” and the “Women’s Right to Know

Resource Directory.”

_____ I believe that I have sufficient information to give this informed consent.

This Form has been fully explained to me. I have read it or have had it read to me, the blank spaces have been

filled in, and I believe that I understand what it says. By my signature below, I give my voluntary consent to

have the surgical and medical procedures performed on me that am listed above.

_____________________________________________________________

Printed Name of Patient

_____________________________________________________________ _______________________

Signature of Patient Date

Planned Parenthood Corporate Office: 4600 Gulf Freeway Ste. 300, Houston, TX 77023 [713-522-6240]

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Part V: Physician Declaration

I and/or my assistant have explained the procedure and the contents of this Form to the patient and her

parent, legal guardian, or managing conservator as required and have answered all questions. To the best of

my knowledge, the patient and her parent, legal guardian, or managing conservator have been adequately

informed and have consented to the above-described procedure.

_____________________________________________________________ ___________________

Signature of Physician Date

Part VI. Parental Consent for Surgical or Medical Procedures.

To meet the Parental Consent Requirement, one of the parents, the legal guardian, or the managing

conservator of the patient must initial each page of this Form and complete Part VI of this Form. An initial on

each page blank means that the parent, legal guardian, or managing conservator has had the opportunity to

read the information (or to have the information read to them) and has had the opportunity to ask questions to

the physician or the physician’s assistant about this information. The signature of the parent, legal guardian, or

managing conservator means that the person signing is agreeing to have the abortion procedures performed

on the patient as set out above.

Parental Consent Statement:

_____ I understand that the doctor listed above is going to perform an abortion on the patient, which will end

her pregnancy and will result in the death of the fetus.

_____ I have had the opportunity to read this Form (or have it read to me) and have initialed each page.

_____ I have had the opportunity to ask questions to the physician or the physician’s assistant about the

information in this Form and the surgical and medical procedures to be performed on the patient.

_____ I believe that I have sufficient information to give this informed consent.

By my signature below, I state and affirm that I am the patient’s:

Father Mother Legal Guardian Managing Conservator

By my signature below, I give permission for ___________________________________________________ (print

the name of patient).

______________________________________________________________________________

Printed Name of Parent, Legal Guardian, or Managing Conservator

______________________________________________________________________________

Signature of Parent, Legal Guardian, Date or Managing Conservator

Part VII. Authentication of Parent, Legal Guardian, or Managing Conservator.

The signature of the parent, legal guardian, or managing conservator must be authenticated. This means that

the parent, legal guardian, or managing conservator must sign Part V of this Form in front of a person who is a

notary public.

The signing in front of a person who is a notary public can occur at any time and at any place prior to the

procedure. The signed and initialed form with the notary statement then can be brought to the physician’s

office or clinic by the patient.

These signing requirements do not require the parent, legal guardian, or managing conservator to be present

with the patient at the time of the procedure.

To be completed by the notary public who notarizes the signing by the parent, legal guardian, or managing

conservator, as provided in Part V, above:

State of Texas §

§ County of ____________________ §

This instrument was acknowledged before me on the _____ day of ________________________________, A.D.,

20______

by _____________________________________________________________________ (print name).

________________________________________________________________

Notary Public, State of Texas

(SEAL) My commission expires: _________________________

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