Appointment Request (Surgical)

Regarding

Important

Please read the information about this procedure.

Surgical Abortion Information

We understand that deciding to have an abortion can be a difficult choice for women. Our team is here to provide personalized care in a safe environment. Surgical abortion is a common procedure in Canada, with a low rate of complications. Before the procedure, we will determine the duration of your pregnancy through an ultrasound and pelvic examination. During the procedure, the doctor will numb the cervix with local anesthesia and a nurse will offer painkillers and relaxation medication.

For pregnancies of 4-7 weeks, the Manual Vacuum Aspiration Abortion procedure is performed. For pregnancies of 7-12 weeks, the doctor will gently open the cervix and use a vacuum aspirator to remove the pregnancy. The procedure takes about 4-8 minutes.

For pregnancies of 14-18 weeks, there are two options. Option 1 involves taking medication to soften the cervix, and the procedure can be completed after 2 hours. Option 2 requires the insertion of laminaria to gradually open the cervix. The laminaria will be removed the next day, and the procedure takes about 10-15 minutes.

We are here to support you throughout the process and provide the necessary information for each stage of the surgical abortion procedure.

Full Name *

Email *

Phone *

I have a valid Ontario Health Card

Yes

No

I have private health care insurance

Yes

No

I am very fluent in English (Verbally and Written)

Yes

No

Do you have a positive pregnancy test?

Yes

No

How was this pregnancy confirmed?

At Home – Urine Test

At Doctors Office – Urine Test

At Doctors Office – Blood Test

At Doctors Office – Ultrasound

Have you been pregnant before?

Yes

No

If you have been pregnant in the past, what kind of pregnancies have you had?

Lists of any complications you have had during or after any delivery or abortion

Do you take Iron or B12 supplements?

Yes

No

Are you anemic?

Yes

No

Have you had any allergic reactions to medications or latex?

Yes

No

Do you have any medical conditions or health problems?

(eg. Anemia, blood clotting disorder)

List any medications your are taking on a daily basis:

What is your height?

What is your weight?

When was the 1st date of your last period?

Notes

I have read the SURGICAL ABORTION information details above *

Yes