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I acknowledge that at least 24 hours before the scheduled abortion I have received a physical copy of each of the following: If any of the above listed documents were transmitted by facsimile, I certify that the documents were clear and legible.

I acknowledge that the physician who will perform the abortion has orally described all of the following to me: I understand that I may sign this form if I have made payments to the physician or an agent of the physician, in whole or in part, for medical services provided to or planned for me, as long as I did not make such payments within 24 hours after I scheduled an abortion to be performed by the physician and/or I did not make such payments within 24 hours after the physician or a qualified person assisting the physician personally gave me a copy of the written materials listed in paragraphs (1.), (2.), and (3.) in the consent form above. Meet for the first time in a populated, public location – never in a private or remote location. Inform a friend or family member of your plans and when and where you're going.CONNECT WITH US "Since 2009, Infonetica has provided Synexus with an effective Good Clinical Practice training program which they translated into 6 different languages for us.I, _______________________________________ , hereby authorize Dr. ___________________________________ ("the physician") and any assistant designated by the physician to perform upon me the following operation(s) or procedure(s): (Name of operation(s) or procedure(s)) I understand that I am approximately _____ weeks pregnant.I consent to an abortion procedure to terminate my pregnancy.I understand that I have the right to withdraw my consent to the abortion procedure at any time prior to performance of that procedure.

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