Name First name * Surname * Date of birth (dd-mm-yyyy) * Before proceeding with medical termination of pregnancy using MS-2 Step (mifepristone, misoprostol) please read the following information carefully and click each point to indicate you have understood and agree with the information provided to you. Any specific concerns should be discussed with your doctor prior to submitting the consent form. Risks of treatment consent The nature, consequences and risks of this treatment have been explained, as well as alternatives, including surgical termination and not proceeding with treatment. Potential side effects consent Potential side effects and risks of this treatment include but are not limited to: excessive or prolonged bleeding, severe cramping which is not relieved by pain medication and nausea, vomiting, diarrhoea, dizziness, headache fever and chills. Chance of failure consent Overall, there is a 2-7% chance of treatment failure requiring a surgical procedure to complete the termination process. Risk of harm to foetus consent There is around a 1% chance treatment will fail to end the pregnancy. In this case, or if the treatment is not completed once it has begun, there is a risk the medications may harm the foetus if pregnancy continues. Surgical termination is strongly recommended. Chance of surgery consent There is a 1-4% chance of requiring surgery to treat retained pregnancy tissue or clot (incomplete abortion). Chance of surgery for bleeding consent There is approximately a 1 – 2% chance of requiring surgery to manage ongoing or heavy bleeding. Risk of blood transfusion consent There is approximately a 0.1 – 0.2% risk of requiring a blood transfusion due to haemorrhage (heavy bleeding). Serious infection consent Although serious infections are very rare in a medical termination of pregnancy, they can be potentially life threatening. Symptoms of persistent abdominal pain or feeling unwell or feeling weak with or without a fever following the treatment require medical review by a doctor without delay. Clear instructions provided consent I have been provided with clear instructions on how and when to take the medications and received written information about the treatment and aftercare. Awareness of emergency care consent I have discussed and am aware of how I will access emergency care should it be required. Follow up appointment consent I must comply with follow up arrangements as advised by the doctor including blood tests and making myself available for a follow up telephone interview. I have provided accurate contact details for this purpose. Options explored consent I am satisfied that I have been given the opportunity to explore all options regarding my pregnancy and have had the opportunity to ask questions and am satisfied with the answers received. Personal information consent I am aware my personal information will be collected and used for the purpose of my care and well-being and in accordance with reporting requirements under legislation or for publication in a non-identifiable format for training or research purposes. Accept and consent I understand and accept the above information and consent to medical termination of pregnancy with MS-2 Step.