_·.};t-""-i,....,..<:X>=\.,._,,l"'---1-h-t:-~>.+\'fl~~.,...___ _ _ _ DOB ~lo Date ti:: 2J(.

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Patient
,.
Name
PROC]iDURESUMMARY

· Pelvic exam: Uterus _ _ _ _ _ _ _.....:.:::

✓-------------------~
Reinoved _ _ _ _ _ _ S:
__# lams_---'\_ _ _ _ _ _# gauze
Dilated to:._ _ _ _ _ _ _ _ _ _ _ Cervix Si!:~• ~~
l-._2--0==--=---· cc Aspirated with _ _ _ _ _l_l--==---~- mm cannula
· EBL _ _ _ _ _

Curette: Yes _ _L/f.lc_o _ _ Path specimen submitted Yes _ _ ~o t..---

Forceps: Y~s-~✓- No _ _ Fetal Foot measure __L-=~3....,_____

Diagnosis: Est. Gestation age: ____\..::..-:,--_·

_ _ _ _ _ _ _ weeks

Patient response dP ~=j"--\_·_::_.____ Completion t i m e _ ~ - - - - - - - - -

Other (special instructions, technical problems: complication): _ _ _ _ _ _ _ _ _ _ _ _ _ __

B f/\b..\- ~)) ~~ ,
. l
f' C\!: ,.:......,\..._ , Q.) \&\.'-:: ; -ru-\--.

Physician's Signature _ _ _ _ _·_· ~-~J______________I 13 EXHIBIT