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The
Following Must Be Completed By
Physician Performing The Abortion
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_____________________________________________________________________
Name
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_____________________________________________________________________
Name Of Facility Where Procedure Will Be Performed
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_____________________________________________________________________
City And State Where Facility Is Located
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_____________________________________________________________________
Name Of Malpractice Insurance Company
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_____________________________________________________________________
State Where Insurance Company Is Located
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_____________________________________________________________________
Policy Number
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$_____________________________
Policy Limit
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___________________________
Date of Expiration
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_____________________________________________________________________
Name Of Nearest Trauma Center Or Emergency
Hospital
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_____________________________________________________________________
Location Of This Trauma Center Or Emergency Hospital
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By
my signature below, I certify that the information above is true
and accurate and that: (a) I am a physician licensed to practice
medicine in the state where this abortion is to be performed. (b)
I have a current and fully paid malpractice insurance policy with
the company named above, (c) my license to practice medicine has
never been suspended or revoked in this or any other state, (d)
I have no claims or judgments against me for medical malpractice,
personal injury or wrongful death, and (e) if you are injured during
your abortion you will be immediately transferred by ambulance to
the emergency facility named above.
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___________________________________________________
Physician's Signature
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__________________
Date
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