Get Report Date Mm/dd/yyyy Texas Department Of State Health Services Induced Abortion Report Form

Filling out the Report Date MM/DD/YYYY Texas Department Of State Health Services Induced Abortion Report Form online can be a straightforward process when you follow the proper steps. This guide will provide clear instructions to help you navigate each section of the form efficiently.

Follow the steps to complete your report form online.

1. Click ‘Get Form’ button to access the report form and open it in your browser.
2. Begin by entering the report date at the top of the form in MM/DD/YYYY format.
3. Next, fill in the facility information including the facility name, facility code, city, and county.
4. In the 'To be completed by patient' section, enter the patient's date of birth in MM/DD/YYYY format. Indicate the marital status by selecting 'Married' or 'Single'.
5. Provide the patient's county and state of residence.
6. Select the patient's race/ethnicity by choosing only one option from the list provided.
7. In the 'To be completed by physician' section, fill in the abortion date and the date of the last menses using MM/DD/YYYY format.
8. Record the number of previous live births and previous induced abortions.
9. Indicate whether the patient viewed the Woman’s Right to Know Act material and completed the abortion and sonogram election form.
10. State if the patient is under 18 years of age and if consent was addressed.
11. Fill in the weeks of gestation and select the method of pregnancy verification.
12. Choose the type of termination procedure from the provided options and specify if applicable.
13. Indicate the type of anesthesia used during the procedure and any complications if they occurred.
14. Document the method used to dispose of fetal tissue and remains as necessary.
15. Confirm if the patient survived the induced abortion and provide the cause of death if applicable.
16. If your facility did not perform abortions, mark the box, sign the form, and prepare to return it via certified mail.

Start filling out the Report Date MM/DD/YYYY Texas Department Of State Health Services Induced Abortion Report Form online today.