Get MAP-235 2000-2022
Address) (Please check appropriate box) Suffered from a ____physical disorder, ____physical injury, and/or ____physical illness that placed her in danger of death if the fetus were carried to term. I further certify that the following procedure(s) were medically necessary to induce an abortion or miscarriage. (Please indicate date and the procedure that was performed) Physician’s Signature Name of Physician License Number Date MAP-235 (2/00) .
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