Oklahoma State Department of Health 11/2013
Health Care Information
Parental Consent Form
for a Minor Seeking Abortion
Parental Statement:
I certify that I, ___________________________, am the parent of _________________________________
(name of parent) (minor daughter name)
and give consent for ____________________________ to perform an abortion on my daughter. I understand
(physician name)
that any person who knowingly makes a fraudulent statement in this regard commits a felony.
Date: , 20 .
Signature of Parent/Managing Conservator/Guardian
I certify I have witnessed the execution of this consent by the parent.
Subscribed and sworn to before me on this day of 20
(day) (month)
NOTARY PUBLIC in and for The State of OKLAHOMA
My commission expires:
Required attachments:
- Copy of government-issued proof of identification
- Written documentation that establishes that he or she is the lawful parent of the pregnant female
Physician Statement:
I, ____________________________, certify that according to my best information and belief, a reasonable person under
(Physician name)
similar circumstances would rely on the information presented by both the minor and her parent as sufficient evidence
of identity.
Date: , 20 .
Signature of Physician
___________
(Parent Initials)
Seal
Page 1 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Consent of a Minor
&
Parental Consent Statement
The law of the State of Oklahoma (Title 63, Section 1-740.13) requires physicians to obtain the consent of the minor and
parent using this form prior to performing an abortion on a minor who is not emancipated.
Risks and hazards that may occur in connection with any surgical, medical, or diagnostic procedure include:
infection
blood clots in veins and lungs,
hemorrhage,
allergic reactions,
death,
Minor’s Initials __________
Risks and hazards that may occur with surgical abortion include:
Hemorrhage
uterine perforation
sterility
injuries to the bowel and bladder
hysterectomy as a result of complication or injury during the procedure
failure to remove all products of conception that may result in an additional procedure,
Minor’s Initials __________
Risks and hazards that may occur with a medical or nonsurgical abortion, include the following:
Incomplete abortion - very rarely - possibly requiring a surgical abortion procedure.
Heavy bleeding - very rarely.
Painful cramping.
Allergic reaction to drugs - very rarely.
Nausea and/or vomiting.
Diarrhea.
Fever.
Infection - very rarely - an infection develops in the uterus. Medication might be needed to clear infection.
Fertility can be diminished in very rare instances as a consequence of infection.
Very rarely - emergency treatment for any of the above problems, including the possible need to treat with
an operation, medicines, or blood transfusion.
Very rarely - death.
Methotrexate and misoprostol can cause serious birth defects if your pregnancy does not end.
Some women should not be given the medicines used for a medical abortion, such as women who are too
far along in their pregnancy, have an ectopic pregnancy (a pregnancy outside the uterus), or who are allergic
to certain medications, or women with an IUD (intrauterine device) in place, women who have problems
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By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
with their adrenal glands (chronic adrenal failure), or who take medicine to thin their blood or take certain
steroid medicines should not have a non-surgical abortion. You should discuss with your physician whether
you have any medical conditions that would make a medical abortion unsafe for you.
Minor’s Initials __________
Please review the applicable description of the procedure and the associated risks and hazards planned for the minor
(Minor should initial the applicable procedure):
Medical (Nonsurgical) Abortion
Medical abortion is a way to end a pregnancy by using an abortion inducing drug as an alternative to surgical
procedures. The Food and Drug Administration allows this type of abortion up to 49 days (7 weeks) after the last
menstrual period. The gestational age must be determined before a physician can administer these drugs to a
pregnant woman.
The physician administering the medicines (such as Mifepristone RU 486) for medical termination of early
pregnancy must be able to provide surgical intervention or have made plans for provision of such care through
other qualified physicians, and be able to assure patient access to medical facilities equipped to provide blood
transfusions and resuscitation, if necessary.
Methods of Non-surgical Abortion
Oklahoma law (Title 63 O.S. §1-729a) states that the physician administering any abortion inducing drug must be
able to determine the duration of the pregnancy accurately, be able to diagnose ectopic pregnancies, be able to
provide surgical intervention or have made plans for provision of such care through other qualified physicians,
and be able to assure patient access to medical facilities equipped to provide blood transfusions and
resuscitation, if necessary. The physician administering Mifepristone (RU 486) is required to fully explain the
procedure to the patient including whether the physician is using the drug in accordance with the U.S. Food and
Drug Administration tested and authorized protocol. If the physician is using an evidence-based regimen, the
physician must provide detailed information on the regimen being used. In addition, the physician who is
prescribing, dispensing, or otherwise providing an abortion inducing drug must be physically present in the same
room as the patient when the drug or chemical is first provided to the patient (Title 63 O.S. §1-729.1)
Mifepristone (RU 486), Misoprostol, and Methotrexate are drugs used in regimens for medical termination of
early pregnancies. These drugs are given by mouth or placed in the woman’s vagina. These drugs cause abortion
by causing the uterus to contract and expel the fetus and placenta.
After receiving these drugs, you might experience cramping and bleeding, pass clots, tissue, and the unborn
child within hours or days. Some amount of bleeding is common following a medical abortion.
Your doctor will tell you when you need to return to be checked. If you are still pregnant at that visit, you will be
given a second drug either by mouth or vaginally. You will be instructed when to return for an important follow-
up visit. Your doctor will determine whether your pregnancy has completely ended. If you are still pregnant, a
surgical procedure could be necessary.
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By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Possible Complications of Non-surgical Abortion
o Incomplete abortion - very rarely - possibly requiring a surgical abortion procedure.
o Heavy bleeding - very rarely.
o Painful cramping.
o Allergic reaction to drugs - very rarely.
o Nausea and/or vomiting.
o Diarrhea.
o Fever.
o Infection - very rarely - an infection develops in the uterus. Medication might be needed to clear
infection.
o Fertility can be diminished in very rare instances as a consequence of infection.
o Very rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or blood transfusion.
o Very rarely - death.
o Methotrexate and misoprostol can cause serious birth defects if your pregnancy does not end.
Minor’s Initials __________
Manual Vacuum Aspiration (MVA)
Manual vacuum aspiration (MVA) is a surgical abortion procedure used within 1 to 3 weeks following a missed
menstrual cycle.
To prepare for the procedure, the doctor first opens (dilates) the cervix by gradually stretching with a series of
dilators. A cannula (small tube) and attached syringe is inserted into the uterus. A vacuum is created in the
syringe causing the uterus to be emptied and the tissue of the unborn child to be collected in the syringe.
The termination of the pregnancy is to be confirmed by the examination of the contents of the syringe and a
sonogram, using a vaginal probe, to make certain that all pregnancy related tissue has been completely
evacuated. In addition, for very early stages of pregnancy, the bloodstream is tested to verify the levels of
pregnancy-related hormones to try to better verify the termination of the pregnancy.
Possible Complications of Manual Vacuum Aspiration (MVA):
o Cramping of the uterus or pelvic pain.
o Perforated uterus (a hole in the uterus) - very rarely.
o A cut or torn cervix (cervical laceration) - very rarely.
o Anesthesia-related complication - very rarely.
o Incomplete abortion - very rarely - pregnancy tissue left inside the uterus, repeated vacuum
aspiration may be necessary.
o Infection - very rarely - medication for the infection, or in rare cases, repeated vacuum aspiration
might be needed.
o Fertility can be diminished in very rare instances as a consequence of infection.
o Heavy bleeding - very rarely - a hemorrhage develops; medication, repeated vacuum aspiration,
surgery or blood transfusion might be needed.
o Vary rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or blood transfusion.
o Very rarely - death.
Page 4 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Minor’s Initials __________
Dilatation and Curettage (D&C) with Vacuum Aspiration
This is a surgical procedure used in the first 12 weeks (LMP) of pregnancy. The doctor first opens (dilates) the
cervix by gradually stretching with a series of dilators. Then the doctor empties the uterus with suction. After
suctioning, the doctor may scrape the walls of the uterus to make sure the unborn child, placenta, and contents
of the uterus have been completely removed.
Possible Complications of Dilatation and Curettage (D&C)
o Cramping of the uterus or pelvic pain.
o Perforated uterus (a hole in the uterus) - very rarely.
o Injury to the bowel or the bladder - very rarely.
o A cut or torn cervix (cervical laceration) - very rarely.
o Incomplete abortion - very rarely - pregnancy tissue left inside the uterus, repeated vacuum
aspiration may be necessary.
o Infection - very rarely - medication for the infection, or in rare cases, repeated vacuum aspiration
might be needed.
o Fertility can be diminished in very rare instances as a consequence of infection.
o Heavy bleeding - very rarely - a hemorrhage develops; medication, repeated vacuum aspiration,
surgery or blood transfusion might be needed.
o Very rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or a blood transfusion.
o Very rarely - death.
Minor’s Initials __________
Dilatation and Evacuation (D&E)
Since this procedure is generally used after 12 weeks (LMP) of pregnancy, the doctor will often use ultrasound to
determine how far along you are in your pregnancy.
To prepare for the procedure, the doctor will open (dilate) the cervix. Most women experience some pain, so
the doctor may administer a painkiller: either locally by shots in the area of the cervix, or by a general
anesthetic, or a sedative (which will leave you conscious). The uterus will be scraped and the unborn child and
placenta are removed with medical instruments. After 16 weeks, the unborn child and placenta are removed
piece-by-piece, using forceps or other instruments, followed by a vacuum curette used to remove the placenta
and remaining tissue.
Possible Complications and Risks of Dilatation and Evacuation
o Perforated uterus (a hole in the uterus) - very rarely.
o Blood clots in the uterus - very rarely.
o Injury to the bowel or bladder - very rarely.
o A cut or torn cervix (cervical laceration) - very rarely.
o Infection - very rarely - medication for the infection, or in rare cases, repeated vacuum aspiration
might be needed.
o Fertility can be diminished in very rare instances as a consequence of infection.
Page 5 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
o Incomplete abortion - very rarely - pregnancy tissue left inside the uterus, repeated vacuum
aspiration may be necessary.
o Anesthesia-related complications - very rarely.
o Heavy bleeding - very rarely - a hemorrhage develops; medication, repeated vacuum aspiration,
surgery or blood transfusion might be needed.
o Very rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or a blood transfusion.
o Very rarely - death.
Minor’s Initials __________
Abortion by Labor Induction (Including Intra-Uterine Instillation)
This procedure is generally used after 16 weeks (LMP) of pregnancy and before the viability of the unborn child,
unless such abortion is necessary to prevent the death of the pregnant woman or to prevent impairment to her
health.
In a medically induced abortion, medicines will be used to start labor. Labor induction may require a hospital
stay. These medicines can be put in the vagina, injected in the uterus (womb), or given into the vein
(intravenously or by IV). The medicines used cause the uterus to contract and labor to begin. More than one
drug might be used.
This procedure may take from several hours to several days.
Your doctor may find it necessary to use instruments to scrape the uterus and make sure that the unborn child,
placenta, and other contents of the uterus have been completely removed.
Possible Complications of Abortion by Labor Induction
o Nausea.
o Vomiting.
o Diarrhea.
o Fever.
o Anesthesia - related complications - very rarely.
o A cut or torn cervix (cervical laceration) - very rarely.
o Blood clots in the uterus - very rarely.
o Adverse reactions to the medications - very rarely.
o Heavy bleeding - very rarely - a hemorrhage develops; medication, repeated vacuum aspiration,
surgery or blood transfusion might be needed.
o Infection - very rarely - medication for the infection, or in rare cases, vacuum aspiration might be
needed.
o Fertility can be diminished in very rare instances as a consequence of infection.
o Very rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or a blood transfusion.
o Very rarely - death.
Who should not have an abortion by medical induction?
Some women should not have a medical induction such as a woman who has had previous surgery to the uterus
or a woman with placenta previa (misplaced placenta). You should discuss with your doctor if you are one of
these women.
Page 6 of 9
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page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Minor’s Initials __________
Dilatation and Extraction (D&X)
Dilatation and Extraction (D&X), referred to in political terminology as partial birth abortion, is a procedure that
has been used generally after 16 weeks (LMP) of pregnancy. When conditions occur that permit the use of this
abortion method, the following procedure is used:
The doctor will dilate (open) the cervix by gradually stretching with a series of dilators. Once the cervix is
sufficiently dilated, the body is extracted through the dilated cervix (intact) to minimize uterine or cervical injury
to the woman from instruments or fetal bones, after which the doctor will suction the intracranial contents,
collapsing the skull.
This surgical method is similar to the D&E procedure except that suction evacuation of the intracranial contents
occurs after the extraction of the intact body of the unborn child through the dilated cervix.
Possible Complications of Dilatation and Extraction
o A cut or torn cervix (cervical laceration) - very rarely.
o Anesthesia - related complications - very rarely.
o Blood clots in the uterus - very rarely.
o Heavy bleeding - very rarely - a hemorrhage develops; medication, or blood transfusion might be
needed.
o Incomplete removal of the placenta, or contents of the uterus - very rarely- vacuum aspiration may
be necessary.
o Infection - very rarely - medication for the infection, or in rare cases, repeated vacuum aspiration
might be needed.
o Fertility can be diminished in very rare instances as a consequence of infection.
o Very rarely - emergency treatment for any of the above problems, including the possible need to
treat with an operation, medicines, or a blood transfusion.
o Very rarely - death.
Minor’s Initials __________
Page 7 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Minor’s consent
By signing below I am indicating that I understand and/or agree to the following:
The doctor is going to perform an abortion on me which will end my pregnancy and result in the death of the unborn
child. Minor’s Initials __________
I am not being forced to have an abortion and I understand that I have the choice not to have the abortion and may
withdraw consent prior to the abortion. Minor’s Initials __________
I give permission for the procedure (initialed above). Minor’s Initials __________
I understand that there are risks and hazards that could affect me if I have the surgical or medical procedures
planned for me. Minor’s Initials __________
I have been given the opportunity to ask questions about my condition, alternative forms of treatment, risks of not
receiving treatment, the procedures to be used, and the risks and hazards involved. Minor’s Initials __________
I have been given information required by Section 1-730 et seq. of this title. Minor’s Initials __________
I have sufficient information to give informed consent. Minor’s Initials __________
Date: , 20 .
Signature of Minor
Page 8 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
This section to be completed by the Parent/Guardian/ Legal Conservator in the presence of a
NOTARY PUBLIC in and for The State of OKLAHOMA.
By signing below I am indicating that I:
a. understand that the doctor signing the physician declaration is going to perform an abortion on the minor
which will end her pregnancy and result in the death of her unborn child,
b. that I, the parent or legal guardian, had the opportunity to read this form or have it read to me and I have
initialed each page,
c. that the parent or legal guardian 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
minor,
d. that the parent or legal guardian believes he or she has sufficient information to give informed consent, and
e. that by the parent or legal guardian's signature, the parent or legal guardian affirms that he or she is the
minor's parent or legal guardian;
Date: , 20 .
Signature of Parent/Managing Conservator/Guardian
I certify I have witnessed the execution of this consent by the parent.
Subscribed and sworn to before me on this day of 20
(day) (month)
NOTARY PUBLIC in and for The State of OKLAHOMA
My commission expires:
Seal
Page 9 of 9
By initialing I, the Parent/Managing Conservator/Guardian, am indicating that I have read understand the information included on this
page. Parent’s Initials ______
Oklahoma State Department of Health 11/2013
Health Care Information
Physician declaration
I, the physician, have explained (or my assistant on my behalf) the procedure and the contents of this form to the minor
and her parent or legal guardian, as required, and have answered all questions. Further, to the best of the my
knowledge, the patient and her parent or legal guardian have been adequately informed and have consented to the
procedure.
Date: , 20 .
Signature of Physician preforming the procedure
