Surgical Patient Information Form

Please Confirm Visit Type: (required)Surgical AbortionMedical Abortion Pill

Email: (required)

INSURANCE PAYMENT AUTHORIZATION AND RELEASE: I hereby authorize my insurance benefits to be paid directly to Choices Women’s Medical Center, and acknowledge that I am financially responsible for any unpaid balance. I also authorize Choices Women’s Medical Center to release any information required by my insurance company. I know it is a crime to fill out this form with facts I know to be false or to leave out facts I know are important.

PERMISSION TO TREAT: I hereby give Choices Women’s Medical Center permission to evaluate and treat the above named patient.

(BY ENTERING YOUR NAME HERE, YOU ARE COMPLETING A DIGITAL SIGNATURE)(required)

Signature Date: (required)

I would like to receive Choices Monthly email Newsletter:
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May we contact you via text/email/ and phone?
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