Download and use this form as a Verification of your pregnancy in the State of Michigan.
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