PATIENT FORMS In order to reduce the amount of time spent at your appointment, please print and fill out the Patient Forms below. Bring them with you to your scheduled appointment.
Femi-care Surgery Center Patient Forms
Patient’s Medical History [PDF ]
Emotional Evaluation [PDF ]
Medical Abortion Consent [PDF ]
Surgical Abortion Consent [PDF ]
Anesthesia Billing Consent [PDF ]
HIPPA form [PDF ]
Patient & Insurance Info [PDF ]
Patient Responsibility [PDF ]
Receipt of Notice of Privacy Practices [PDF ]
Advance Directive [PDF ]
Information on Advance Directives [PDF ]
Physician Ownership Disclosure [PDF ]
Refund Prices [PDF ]
Other Options for TA [PDF ]
Medical Records Release [PDF ]
