Figure: 25 TAC §139.52(a)(1)


Each item on this certification form shall be reviewed. The woman should place her initials beside each statement and sign the bottom of the form.

I certify that the following information was presented to me, at least 24 hours prior to the abortion, by the physician who is to perform the abortion or by the referring physician:

_____  the name of the physician who will perform the abortion;

_____  the particular medical risks associated with the particular abortion procedure to be             employed; including when medically accurate:

_____  the risk of infection and hemorrhage;

_____  the potential danger to subsequent pregnancy and of infertility; and

_____  the possibility of increased risk of breast cancer following an induced                        abortion and the natural protective effect of a completed pregnancy in                        avoiding breast cancer.

_____  the probable gestational age of the unborn child at the time the abortion is to be                         performed; and

_____  the medical risks associated with carrying the child to term.

The physician who is to perform the abortion or the physician’s agent has informed me that:

_____  medical assistance benefits may be available for prenatal care, childbirth, and neonatal             care;

_____  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;

_____  public and private agencies provide pregnancy prevention counseling and medical
            referrals for obtaining pregnancy prevention medications or devices; and

I have also been informed that:

____    I have the right to review the printed materials prepared by the Department of State
            Health Services entitled the "A Woman's Right to Know" booklet and the resource             directory, which describe the unborn child and list agencies that offer alternatives to             abortion, and that those materials shall be given to me if I choose to view them;

I made the following choice (choose one of the following):
          _____  I requested and was provided a printed copy of "A Woman's Right to Know"
                      booklet and the resource directory.
          _____  I chose to review the "A Woman's Right to Know" materials on this website.
          _____  I declined the informational materials.

Signature                                                                                                         Date

Printed Name