Patient Identification Number: 7018

You have the right to information about your health condition and the following risks and hazards that may occur in connection with your planned care. Please read and initial the following blanks to indicate your voluntary and informed consent to proceed with the medical and/or surgical procedure:

_____ I understand that the physical risks associated with the procedure include, but are not limited to, menstrual-like cramping, infection, allergic reaction to other people’s babies, uterine perforation, increased alcohol consumption, sterility, hemorrhage, death, and/or possible continuation of the pregnancy.

_____ I understand that I may experience light to moderate bleeding for up to four weeks following the procedure.

_____ I understand that though it was not my choice to listen to the Jackson 5 during the procedure, I will now think of their seminal hits every time I smell isopropyl alcohol in my vicinity.

_____ I understand that though I will likely get cancer, because everything leads to cancer, this will not be directly related to the procedure, despite what the protesters outside the clinic have threatened.

_____ I understand that, due to the personal beliefs of various family members, I will not discuss the procedure publicly.

_____ I understand that I will feel guilt, not because I chose to undergo this procedure, but because I cannot, or will not, speak about it.

_____ I understand that this inclination toward polite silence is a special kind of fucked-up, and I will blame it on my Midwestern upbringing.

_____ I understand that, because of my age, which the physician has referred to as “advanced,” the nurse will hold my hand and say, “Are you sure, sweetie?” before they begin the procedure.

_____ I understand that I will think of this question every time my grandchildless mother calls.

_____ I understand that my partner will begin wearing a silver cross around his neck shortly after the procedure.

_____ I understand that his behavior will cause me to question my own religion before remembering I don’t have one.

_____ I understand that one day I will see a little boy in the park, and I will make a calculation.

_____ I understand that I will immediately try to unmake this calculation.

_____ I understand that, though my partner was the first to say he was not ready, he will remind me often that he has regrets.

_____ I understand that I will try to convince myself that silence does not mean shame.

_____ I understand that eventually the not-telling will make it forever too difficult to admit the truth to my mother about why she is grandchildless.

_____ I understand that within a year I will walk into a frigid room and realize my partner and I have fundamentally different beliefs about where to set the thermostat.

_____ I understand that the relationship will not survive this.

_____ I understand that I will occasionally forget to report the procedure on medical-history questionnaires.

_____ I understand that years later turbulence on an airplane will cause me to tighten my seat belt, and I will suddenly remember the way the physician pressed his fingers against my stomach to get leverage during the procedure.

_____ I understand that this will make it difficult to breathe, but I will attribute it to the altitude.


Signature of Patient