PURPOSE: The Department of Health is given the responsibility to provide physicians 19 CSR 10-15

with consent forms for abortions. This rule establishes the content of the form.

1. (1) The consent form for abortion shall contain the following information:

MISSOURI DEPARTMENT OF HEALTH Division of Health Resources

INDUCED TERMINATION OF PREGNANCY CONSENT FORM

I have been informed by my physician, ____ ____________________________________, of the particular risks associated with the ___________________abortion technique to be used in my case. My physician has also informed me of the alternatives available to me other than an abortion.

________________ _________________ witness signature of patient

________________ _________________ witness date

1. (2) Any physician who performs an abortion, prior to the abortion, shall require the woman to give her informed consent on the Department of Health induced termination of pregnancy consent form or on a form which includes as a minimum the same information as included on the Department of Health form.

AUTHORITY: section 188.039, RSMo 1986 and Planned Parenthood Association of Kansas City v. Ashcroft, 483 F. Supp. 679 (W.D. Mo. 1980). This rule was previously filed as 13 CSR 50-151.040 and 19 CSR 30- 15.040. Original rule filed Feb. 13, 1981, effective June 11, 1981. Changed to 19 CSR 10-15.040 July 30, 1998.