Kansas 24 Hour Informed Consent
-Bring this document with you to your appointment printed on
WHITE PAPER
-Please read and initial each section and sign your name at the
bottom.
-DO NOT mail to Comprehensive Health or Planned
Parenthood.
To comply with Kansas Law effective July 1, 1998 (amended July 1, 2009; July 1, 2011; July 1,
2013; July 1, 2017), you must receive this Informed Consent at least 24 hours prior to your
procedure. The State-written materials referenced within this form are available to you online and
at Comprehensive Health of Planned Parenthood Great Plains.
1. Estimated Gestation of Pregnancy: Until you have a sonogram to determine how far along
the pregnancy is, the best way to estimate the gestation is by the date of your last normal menstrual
period.
If you believe your
last normal menstrual
period started:
Then you are
probably about:
If you believe your
last normal menstrual
period started:
Then you are
probably about:
4 weeks ago
4 weeks pregnant
14 weeks ago
14 weeks pregnant
5 weeks ago
5 weeks pregnant
15 weeks ago
15 weeks pregnant
6 weeks ago
6 weeks pregnant
16 weeks ago
16 weeks pregnant
7 weeks ago
7 weeks pregnant
17 weeks ago
17 weeks pregnant
8 weeks ago
8 weeks pregnant
18 weeks ago
18 weeks pregnant
9 weeks ago
9 weeks pregnant
19 weeks ago
19 weeks pregnant
10 weeks ago
10 weeks pregnant
20 weeks ago
20 weeks pregnant
11 weeks ago
11 weeks pregnant
21 weeks ago
21 weeks pregnant
12 weeks ago
12 weeks pregnant
22 weeks ago
22 weeks pregnant
13 weeks ago
13 weeks pregnant
The final determination will be made by the doctor upon ultrasound examination. If you are between
4 - 12 weeks, the common procedure is Vacuum Aspiration. Medication Abortion is available for
pregnancy termination between 4 - 11 weeks. If you are between 13 - 21.6 weeks the most common
procedure is Dilation and Evacuation.
2. Types of Abortion Procedures:
First Trimester (4-12 wks) Vacuum Aspiration – This abortion procedure begins with a local
anesthetic given to numb the cervix. The cervix is then widened using dilators, which are tapered rods
that gradually increase in size. The physician inserts a small tube (cannula), which is attached to an
aspiration device. The device's suction empties the contents of the uterus through the tube. The
physician may check the walls of the uterus with a curette. The entire procedure
takes less than 10 minutes. Sensations will vary, but they are mostly described as cramping or
discomfort, which generally subsides within a few minutes after the procedure is over.
Early Nonsurgical/Medication Abortion (4-11 weeks or up to 70 days) – While in the clinic, a
drug, Mifepristone, is given to stop the development of the pregnancy. One to two days later, at
home, a second drug (Misoprostol) is taken, causing the uterus to contract and expel the embryo
and placenta. During this process cramping and bleeding will occur.
Second Trimester (13-21.6 wks) Dilation and Evacuation – During the initial appointment, the
osmotic dilators are inserted into the patient's cervix to begin the process of slow and gentle
dilation of the cervix. The abortion procedure occurs several hours later, or in some cases one or
two days later and involves removal of the pregnancy with forceps. A suction instrument is used
to clean the uterus, and a curette is used to check the uterine walls. Patients are then monitored in
recovery for at least 2 hours following the procedure.
Complications of Abortion – Possible complications include: blood clots accumulating in the
uterus, requiring another suction procedure; infections, most of which are easily identified and
treated if the woman carefully observes follow-up instructions; a tear in the cervix, which may be
repaired with stitches; perforation of the wall of the uterus and/or other organs, which may heal
themselves or may require surgical repair or, rarely, hysterectomy; and abortion that is not
complete or that does not end the pregnancy may require the procedure to be repeated; excessive
bleeding due to failure of the uterus to contract, which may require a blood transfusion; death. In
the second trimester, risks increase with every week of gestation.
3. Risks with terminating a pregnancy vs. carrying a pregnancy to term: There is
approximately 1 death for every 167,000 women who have legal abortions and these rare deaths
are usually of adverse reactions to anesthesia, heart attacks, or uncontrollable bleeding. The
death rate for a woman carrying to term is about 10 times greater.
4. Your blood type will be determined the day of your appointment. Approximately 15% of
the population is Rh-negative. All Rh-negative women will receive an injection of Rhogam to
prevent problems with future pregnancies such as miscarriage, severe fetal anemia or permanent
fetal damage. There is no extra cost for a Rhogam injection.
5. State-written materials are available in printed form and online which list agencies which
offer alternatives to abortion with a special section listing adoption services and providers of free
ultrasound services, provide detailed information on the availability of assistance for prenatal
care, childbirth, perinatal, and neonatal care, and contain additional State-mandated information.
A link to the State written materials is available on the Comprehensive Health of Planned
Parenthood homepage, as required by law. The information stated there does not necessarily
reflect current medical opinion or that of Comprehensive Health.
6. Alternatives to abortion include parenting, foster care and adoption. For information
about perinatal resources in Kansas, visit www.kdheks.gov/cf/maternal.html or contact the
Kansas Department of Health and Environment's Perinatal Health Consultant at (785) 296-1307.
For information about national perinatal resources, visit the National Perinatal Association at
wwww.nationalperinatal.org and Bright Futures at www.brightfutures.org.
7. You are free to withhold or withdraw your consent to the abortion procedure at any time
prior to the dilation of the cervix during a surgical abortion or at any time prior to the
administration of the first medication during a nonsurgical abortion. Consent may be withheld or
withdrawn without affecting your right to future care or treatment and without the loss of any
state or federally funded benefits to which you might otherwise be entitled.
8. Provider information by Comprehensive Health location is below. The United States
Supreme Court recently struck down a Texas law requiring doctors providing abortion to have
admitting privileges at a hospital within 30 miles, concluding there was no evidence it advanced
women's health and that abortion is a safe procedure with low rates of serious complications.
Physician’s Name: Orrin Moore, M.D.
Year M.D. Completed: 1976
Date physician’s employment commenced
at Comprehensive Health: 7/6/2004 Kansas
State Board of Healing Arts Disciplinary
Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓ Clinical
privileges at hospital within thirty miles of
Comprehensive Health of Overland
Park? NO □YES ✓
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO □YES ✓
Physician’s Name: Irene Bettinger, MD.
Year M.D. Completed: 1966
Date physician’s employment commenced at
Comprehensive Health: 03/01/2017
Kansas State Board of Healing Arts Disciplinary
Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health?
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓YES □
Physician’s Name: Iman Alsaden, M.D.
Year M.D. Completed: 2014
Date physician’s employment commenced
at Comprehensive Health: 1/7/19
Kansas State Board of Healing Arts
Disciplinary Actions concerning Physician:
NO
✓
YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of
Overland Park: NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Elizabeth Daily, M.D. Year
M.D. Completed: 2013
Date physician’s employment commenced at
Comprehensive Health: 1/14/19
Kansas State Board of Healing Arts Disciplinary
Actions concerning Physician:
NO
✓
YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland Park:
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO □ YES✓
Physician’s Name: Joshua Yap, M.D.
Year M.D. Completed: 2019
Date physician’s employment commenced
at Comprehensive Health: 8/26/19
Kansas State Board of Healing Arts
Disciplinary Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland
Park: NO ✓ YES □
Hospital privileges lost: NO ✓ YES □ Resident
of Kansas: NO ✓ YES □
Physician’s Name: Mansi Shah, M.D.
Year M.D. Completed: 2016
Date physician’s employment commenced
at Comprehensive Health: 12/28/2020
Kansas State Board of Healing Arts
Disciplinary Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland
Park: NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Autumn Davidson, M.D.
Year M.D. Completed: 2008
Date physician’s employment commenced at
Comprehensive Health: 8/20/2020
Kansas State Board of Healing Arts Disciplinary
Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland Park:
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Sarah Spurgeon, M.D.
Year M.D. Completed: 2018
Date physician’s employment commenced
at Comprehensive Health: 12/2/2021
Kansas State Board of Healing Arts
Disciplinary Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty miles
of Comprehensive Health of Overland Park: NO
✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Lisa Netherland, M.D.
Year M.D. Completed: 2013
Date physician’s employment commenced at
Comprehensive Health: 01/11/2022 Kansas State
Board of Healing Arts Disciplinary Actions
concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty miles of
Comprehensive Health of Overland Park: NO ✓
YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Erin Ahart M.D.
Year M.D. Completed: 2020
Date physician’s employment commenced at
Comprehensive Health: 8/22/21
Kansas State Board of Healing Arts Disciplinary
Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland
Park: NO ✓ YES □
Hospital privileges lost: NO ✓ YES □ Resident of
Kansas: NO ✓ YES □
Physician’s Name: Leslie Dunmire, M.D.
Year M.D. Completed: 2020
Date physician’s employment commenced at
Comprehensive Health: 8/22/21
Kansas State Board of Healing Arts Disciplinary
Actions concerning Physician: NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty miles of
Comprehensive Health of Overland Park:
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO□ YES ✓
9. I received this information at least twenty-four (24) hours prior to my procedure.
Complete the following: (must be 24 hours prior to your procedure)
Physician’s Name: Ruth Lehman- Wiens, M.D.
Year M.D. Completed: 2017
Date physician’s employment commenced at
Comprehensive Health: 1/11/20201
Kansas State Board of Healing Arts
Disciplinary Actions concerning Physician:
NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty
miles of Comprehensive Health of Overland
Park: NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO □
YES ✓
Physician’s Name: Courtney Forbis, M.D.
Year M.D. Completed: 2017
Date physician’s employment commenced at
Comprehensive Health: 07/14/2022
Kansas State Board of Healing Arts
Disciplinary Actions concerning
Physician: NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty miles of
Comprehensive Health of Overland Park:
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
Physician’s Name: Emily Brekke, M.D.
Year M.D. Completed: 05/2022
Date physician’s employment commenced at
Comprehensive Health: 07/06/2022
Kansas State Board of Healing Arts
Disciplinary Actions concerning
Physician: NO ✓ YES □
Malpractice insurance: NO □YES ✓
Clinical privileges at hospital within thirty miles of
Comprehensive Health of Overland Park:
NO ✓ YES □
Hospital privileges lost: NO ✓ YES □
Resident of Kansas: NO ✓ YES □
I received this information on DATE: _________________________ TIME: ____________am/pm
(Circle)
Patient Signature: ________________________________________________________________
(Print this document on WHITE PAPER)