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FORM FOR USE BY PHYSICIANS IN AN OFFICE SETTING

EARLY PREGNANCY LOSS

CONFIRMATION OF MISCARRIAGE AND NOTICE OF RIGHT TO FETAL DEATH

CERTIFICATE

This is to certify that _____________________ (woman’s name) had a positive pregnancy test

on ______ (date).

This (was/ was not) confirmed as an intrauterine pregnancy by an ultrasound.

On ______ (date) ___________ (woman’s name):

Select appropriate option:

•Had a negative pregnancy test signifying a miscarriage, ectopic pregnancy, false pregnancy test, blighted ovum, etc. No fetus was ever confirmed or visualized.

•Had a miscarriage of fetal products of conception (placenta, bleeding, etc) confirmed by dropping Beta HCG hormone test. The miscarriage was not, to the best of my knowledge, the result of the purposeful termination of a pregnancy.

•Had a miscarriage of a ___________week fetus/infant that was delivered with no sign of life. The miscarriage was not the result of the purposeful termination of a pregnancy.

Physician Printed Name: ____________________________

Physician Signature: ____________________________ Date: ____________

In the state of __________, you have the option to register your fetal death. If you want to

exercise this option, you must submit this written statement to the local Registrar of Vital Statistics in the district where the fetal death occurred. If the father submits the application, he must also include with this statement a signed and notarized document from you attesting that you voluntarily provided the father with a copy of this statement.

You can use the fetal death certificate to arrange private funeral services and burial. You may also choose to have the physician dispose of the fetal remains in accordance with _________

state law. There is no charge for this service of cremation without ashes. You will need to sign the disposition form designating your choice of disposition of the remains.

Would you like the physician to handle disposal of the fetal remains if fetal remains can be identified. Yes  No 

Signature of Mother: _______________________ Date: _________________________

Common mistakes

Filling out the Miscarriage Discharge Paper form can be a sensitive and emotional task. Many individuals may overlook certain details that are crucial for accuracy. One common mistake is failing to provide the woman’s full name in the designated space. This information is vital for proper identification and documentation.

Another frequent error involves the date of the positive pregnancy test. It’s essential to ensure this date is accurate. An incorrect date can lead to confusion and complications down the line. Additionally, people sometimes forget to indicate whether the pregnancy was confirmed by an ultrasound. This detail is important for medical records and may affect future care.

When selecting the appropriate option regarding the nature of the miscarriage, individuals may not read the choices carefully. Each option has specific implications, and selecting the wrong one can misrepresent the situation. It’s advisable to take your time and choose the option that best reflects the circumstances.

Many people also neglect to include the physician's printed name and signature. This oversight can render the form incomplete. Without the physician’s verification, the document may not hold the necessary weight for legal or medical purposes.

In some cases, individuals may fail to understand the importance of the fetal death registration option. If you wish to register the fetal death, it’s crucial to follow the instructions carefully. Not submitting the written statement to the local Registrar of Vital Statistics can result in missed opportunities for memorialization.

Another mistake is not signing the disposition form, which designates how the fetal remains will be handled. This step is essential, as it ensures that your wishes are respected. Some may overlook this detail, assuming it is optional, but it is a necessary part of the process.

Lastly, individuals sometimes forget to indicate their choice regarding the physician handling the disposal of fetal remains. It’s important to clearly mark 'Yes' or 'No' to avoid any ambiguity. This decision is personal and should reflect your preferences.

Being mindful of these common mistakes can help ensure that the Miscarriage Discharge Paper form is completed accurately. Taking the time to review each section carefully can provide peace of mind during a difficult time.

Dos and Don'ts

When filling out the Miscarriage Discharge Paper form, it is important to approach the process with care and attention to detail. Here are some helpful tips on what you should and shouldn't do:

  • Do ensure accuracy. Double-check all information entered, especially names and dates. Mistakes can lead to complications later on.
  • Do read the instructions carefully. Understanding what each section requires will help you complete the form correctly and efficiently.
  • Do keep a copy for your records. Having a personal copy can be beneficial for future reference or if any issues arise.
  • Do consult your physician if unsure. If any part of the form is confusing, don’t hesitate to ask for clarification from your healthcare provider.
  • Don't rush through the process. Taking your time can prevent errors and ensure that all necessary information is included.
  • Don't leave blank spaces. If a section does not apply, indicate that clearly rather than skipping it. This helps avoid confusion.
  • Don't forget to sign and date the form. Your signature is crucial for the document to be valid and processed.
  • Don't hesitate to seek support. If you're feeling overwhelmed, consider asking a trusted friend or family member for help with the form.
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Similar forms

The Miscarriage Discharge Paper form serves an important role in documenting a woman's experience during early pregnancy loss. It shares similarities with several other important documents. Here are four such documents:

  • Fetal Death Certificate: Like the Miscarriage Discharge Paper, this document officially records the death of a fetus. It is essential for legal and medical purposes, allowing families to arrange for burial or cremation services.
  • Florida Motor Vehicle Bill of Sale: This document is crucial for the transfer of ownership of a vehicle in Florida, outlining key details about the transaction, including the vehicle, seller, and buyer information, which can be verified through resources like https://documentonline.org/blank-florida-motor-vehicle-bill-of-sale.
  • Medical Release Form: This form grants permission for healthcare providers to share medical information. Similar to the Miscarriage Discharge Paper, it ensures that sensitive information is handled appropriately and that the patient’s rights are respected.
  • Patient Discharge Summary: After any medical procedure, this summary outlines the care provided and next steps. It parallels the Miscarriage Discharge Paper in that both documents summarize important medical events and decisions made during a patient’s care.
  • Consent for Treatment Form: This document confirms that a patient has agreed to a specific medical procedure. Much like the Miscarriage Discharge Paper, it emphasizes informed consent and the patient’s understanding of their medical situation.