forms

Patient Forms

Medical History

Please use this form if you are having an abortion procedure at AWC. This form tells us about your medical history. It is extremely important for our physicians and medical staff to know your entire medical history in order to provide the safest care possible.
Medical History

HIPAA Acknowledgement

Please use this form if you are having any service at AWC. By signing this form, you acknowledge that you understand the Health Insurance Portability and Accountability Act. If you have any questions regarding HIPAA, you may speak with our staff on the day of your procedure or call (404) 257-0057.
AWC HIPAA Acknowledgement

HIPAA Disclosure

This form explains the Health Insurance Portability and Accountability Act. If you have any questions regarding HIPAA, you may speak with our staff on the day of your procedure or call (404) 257-0057.
AWC HIPAA Notice of Privacy Practices

How to Choose an Abortion Provider

If you have questions about how to find the best abortion provider for your care, this information will help you ask the right questions to get the care you need.
How to Choose a Quality Abortion Provider

Surgical Forms

1st Trimester Surgical Abortion
Please review this information if you will be having a 1st trimester surgical abortion procedure at AWC. It is very important for you to follow these instructions in order to have a safe surgical procedure.
AWC-Appointment-Confirmation-and-Reminders-for-Patients(2)

2nd Trimester Surgical Abortion (2-Day Procedure)
Please review this information if you will be having a 2nd trimester surgical abortion (2-day procedure) at AWC. It is very important for you to follow these instructions in order to have a safe surgical procedure.

AWC – Appointment Confirmation and Reminders for Patients
AWC DandE info
AWC Overnight Laminaria instructions

Medical Abortion Forms

Post-Operative Instructions
This form details all of the instructions you will be asked to follow after a surgical abortion procedure. Our nursing staff will review all of this information with you on the day of your procedure.
AWC Post Op Instructions

Choosing Medical Abortion
For help deciding which method of abortion is right for you, an excellent workbook can be found online here.

Medical Abortion Information and Instructions
Please review these instructions if you will be having a medical abortion procedure (non-surgical abortion) at AWC. The medical abortion is an option for women who are between 5 – 10 weeks pregnant. It is very important for you to follow these instructions in order to have a safe procedure.
Using Mifeprex AWC Using Mifeprex – Med Guide Alt Tx Plan

Medical Abortion Consent & Treatment Plan
This form will explain the medical abortion procedure in detail– what medications are used, the FDA regimen, what medical conditions are not indicated for MAB use and other important information. If you have questions any questions regarding the medical abortion, you may speak with our staff on the day of your procedure or call (404) 257-0057.
AWC MAB Consent Forms

Medical Abortion Discharge Instructions
This document provides information about what to do following the start of your medical abortion procedure and information about what to expect throughout the process. If you have questions any questions regarding the medical abortion, you may speak with our staff on the day of your procedure or call (404) 257-0057.
AWC MAB Discharge Instructions

Parental Notification

Please use this form if you are under 18 years of age. Your parent or legal guardian must sign this form and bring proof of ID to your appointment. If you have questions about the Georgia laws related to parental notification, please click here (link to parental notification page).
AWC Parental notification consent

Medical Records Release

Please use this form if you would like a copy of your medical records for yourself or your doctor. Please fax a completed release form to (404) 257-1245 or bring the release to our office in person.
AWC Medical Records Release Form

Credit Card Authorization

Please use this form if you are paying by credit card and the cardholder is unable to be present on the date of service.  The cardholder must complete this form with a copy of his or her identification and both sides of the credit card. Patients must bring the completed form with the required information to their appointment.
AWC Credit Card Authorization Form