Free Michigan Pregnancy Verification Form - PDF Form Download

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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

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