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