Mifepristone Tablets, 200 mg
Healthcare Providers: Counsel the patient on the risks of mifepristone. Both you and the patient must provide a written or
electronic signature on this form.
Patient Agreement:
1. I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my healthcare provider's advice about
when to take each drug and what to do in an emergency.
2. I understand:
a. I will take mifepristone on Day 1.
b. I will take the misoprostol tablets 24 to 48 hours after I take mifepristone.
3. My healthcare provider has talked with me about the risks, including:
• heavy bleeding
• infection
4. I will contact the clinic/office/provider right away if in the days after treatment I have:
• a fever of 100.4°F or higher that lasts for more than four hours
• heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)
• severe stomach area (abdominal) pain or discomfort, or I am “feeling sick,” including weakness, nausea, vomiting, or
diarrhea, more than 24 hours after taking misoprostol – these symptoms may be a sign of a serious infection or another
problem (including an ectopic pregnancy, a pregnancy outside the womb).
My healthcare provider has told me that these symptoms listed above could require emergency care. If I cannot reach the
clinic/office/provider right away, my healthcare provider has told me who to call and what to do.
5. I should follow up with my healthcare provider about 7 to 14 days after I take mifepristone to be sure that my pregnancy has
ended and that I am well.
6. I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use this treatment. If
my pregnancy continues after treatment with mifepristone and misoprostol, I will talk with my provider about a surgical procedure
to end my pregnancy.
7. If I need a surgical procedure because the medicines did not end my pregnancy or to stop heavy bleeding, my healthcare
provider has told me whether they will do the procedure or refer me to another healthcare provider who will.
8. I have the MEDICATION GUIDE for mifepristone.
9. My healthcare provider has answered all my questions.