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Free Michigan Pregnancy Verification Form - PDF Form Download

Michigan Pregnancy Verification Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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Download and use this form as a Verification of your pregnancy in the State of Michigan.

Michigan Pregnancy Verification Form


Text Version of this Form

VERIFICATION OF PREGNANCY AND GESTATIONAL AGE
By Local Health Department
Michigan Department of Community Health

I certify that on ____________ (date) at ________________ (time) at the

________________ health department, the pregnancy of

_____________________ (patient) was confirmed.
At this time, the gestational age of the fetus is ____________________.

____________________________________ ____________
Signature of Local Health Department Official Date Signed

Authority: PA 345 of 2000

Completion: IS REQUIRED, if the patient requests a pregnancy verification and
determination of gestational age in order to fulfill the requirements of the
Informed Consent for Abortion Law, PA 345 of 2000.

Copy Distribution: Patient
Local Health Department

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