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Preview - Miscarriage Discharge Paper Form
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: _________________________
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Death Certificate: Similar to the Miscarriage Discharge Paper, a death certificate officially records the death of an individual. It includes essential information such as the deceased's name, date of death, and cause of death, providing a legal acknowledgment of the event.
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Fetal Death Certificate: This document specifically pertains to the loss of a fetus. Like the Miscarriage Discharge Paper, it serves to document the fetal death and may be used for burial arrangements, fulfilling legal requirements in many jurisdictions.
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Medical Discharge Summary: A medical discharge summary provides an overview of a patient’s condition upon leaving a healthcare facility. It includes treatment details and follow-up care instructions, similar to how the Miscarriage Discharge Paper outlines the medical status of the pregnancy.
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Patient Care Plan: A patient care plan outlines the treatment and care strategies for a patient. While it focuses on ongoing medical care, it parallels the Miscarriage Discharge Paper by documenting important health information and decisions made during a critical time.