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;
father is liable for assistance in the support of the child without regard to
the father has offered to pay for the abortion;
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
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.