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Patient Statement

Print Out and Sign at Least 24 Hours in Advance of Procedure

The law requires that you certify that you have had access to the materials outlined in the Women’s Right To Know Act at least 24 hours before an abortion procedure. So you will need to:

  • Print this page. You should see an accurate time and date stamp on the printed copy — it proves that you had the opportunity to review the information 24 hours before terminating your pregnancy as required under a 2010 amendment to the S.C. Women’s Right to Know Act.
  • Sign the form and print your name in the spaces indicated.
  • Take the completed form with you to the abortion clinic or hospital and give it to the physician or the staff assisting the physician.

 

I, ____________________________________________________________________________________,
(signature)

acknowledge that I have had the opportunity to review either online or in printed form the information at DHEC’s “Information Outlined in the S.C. Women’s Right to Know Act” website, as specified in the S.C. Women’s Right to Know Act.

Print Name: ___________________________________________________________________________

Date / Time: ______________________________________

Printed:

Staff Phone, Email Info | DHEC Locations | Organizational Charts