(c) Develop, draft, and print, in nontechnical English, Arabic, and Spanish, an acknowledgment and consent form that includes only the following language above a signature line for the patient: "I, _____________________________, voluntarily and willfully hereby authorize Dr. __________________ ("the physician") and any assistant designated by the physician to perform upon me the following operation(s) or procedure(s):
__________________________________________________________
(Name of operation(s) or procedure(s))
__________________________________________________________
A. I understand that I am approximately _____ weeks pregnant. I consent to an abortion procedure to terminate my pregnancy. I understand that I have the right to withdraw my consent to the abortion procedure at any time before performance of that procedure.B. I understand that it is illegal for anyone to coerce me into seeking an abortion.C. I acknowledge that at least 24 hours before the scheduled abortion I have received a physical copy of each of the following:1. A medically accurate depiction, illustration, or photograph of a fetus at the probable gestational age of the fetus I am carrying.2. A written description of the medical procedure that will be used to perform the abortion.3. A prenatal care and parenting information pamphlet.D. If any of the documents listed in paragraph C were transmitted by facsimile, I certify that the documents were clear and legible.E. I acknowledge that the physician who will perform the abortion has orally described all of the following to me:1. The specific risk to me, if any, of the complications that have been associated with the procedure I am scheduled to undergo.2. The specific risk to me, if any, of the complications if I choose to continue the pregnancy.F. I acknowledge that I have received all of the following information: 1. Information about what to do and whom to contact in the event that complications arise from the abortion.2. Information pertaining to available pregnancy related services.G. I have been given an opportunity to ask questions about the operation(s) or procedure(s).H. I certify that I have not been required to make any payments for an abortion or any medical service before the expiration of 24 hours after I received the written materials listed in paragraph C, or 24 hours after the time and date listed on the confirmation form if the information described in paragraph C was viewed from the state of Michigan internet website.".