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Financial Assistance requested
Offices of: "Life Enterprises Unlimited" County of: "Mobile" , Alabama I, __________________________________, being now of sound mind and body, do hereby release "This Clinic" and all personnel associated with them, be it doctors, nurses or other staff members, from all present and future claims arising from all procedures used by same. I recognize that there are inherent risks in such procedures, both physical and psychological, and I do willingly accept such consequences from such services both potential and actual. I acknowledge that the following lists of hazards are only partial lists: (Initial each acceptance) _________ I acknowledge that there is a thirty percent (30%) risk probability of being sterile for the rest of my life, i.e. that I may never be able to get pregnant in the future, or will have spontaneous miscarriages or ectopic `tubal' pregnancies, even though I may later have a strong desire to have one or more babies: _________ I acknowledge that there is a real risk of internal bleeding and even of hemorrhaging, and that there is a risk of my own death (it is understood that the death of the living person within my womb is what I desire to occur): _________ I acknowledge that the following may and do at times occur following an abortion procedure: Abdominal Cramps - Allergies - Amnesia - Antibiotic Reaction - Bacterial Infection - Pelvic or Peritoneum Inflammation - Blood Poisoning - Isoimmunization - Cervical Adhesions and/or Lesions - Cervical Rupture or Detachment - Punctured Vagina - Incomplete or Failed Abortion - Incomplete Separation of Placenta - Expulsion of Fetal Parts into Abdomen - Embolisms - Myocardial Infraction - Breast Engorgement - Ovary Loss - and possible Shock Collapse: _________ I acknowledge that if any of the following occur, major surgery may be required or that death could follow: Perforated or ruptured Bowel, Bladder or Uterus - Bowel Extraction - Ectopic (Tubal) Pregnancy: _________ I acknowledge that there is a probable Eighty-Seven Percent (87%) chance that at least several and often as many as fifty percent (50%) of the following psychological problems will occur following an abortion procedure (Note: If I submit to an abortion I will, at least in time, come to recognize my decision as the taking of the life of an innocent living unborn baby, my child, which will never nurse at my breasts, be able to call me "mommy", or, be able to be held in my arms and be cared for. I may never know what it truly means to have someone fully desire my love and affection giving me their unquestioning love in return while being able to share with him or her the knowledge I possess) - Desire to replace aborted child - Feelings of regret, guilt, un-forgiveness, victimization and betrayal - Intense Headaches - Experiencing Haunting Baby Ghosts - Withdrawal from friends and society - Having casual sex or becoming lesbian with probable hatred of men, or just total fear of sexual activity (Frigid) - Insomnia - Stomach Disorders - Alcohol and/or drug abuse (sought after for the purpose of drowning my sorrows over the loss of my child) - Hear Crying of Baby -Obsession with anniversaries of Date of Abortion and expected Date of Birth of Child, with frequent Flashbacks of the abortion event itself including but not limited to the sound of the Vacuum device used to suck my baby apart and extracting it in pieces from within me - Hatred of Others Involved in Abortion Decision - Abuse of Spouse, living children (if any), or other Persons who happen to be around during a fit of Consuming Guilt, Depression and Despair - Unresolved Feelings - Unrest - Denial that there was a pregnancy, or that I was responsible for its termination - Bulimia or going to either extreme of Anorexia or Over Eating: _________ I acknowledge that I will have to frequently `Suppress my Grief and Emotions' because of Shame and Guilt over what I want to have done particularly when in the company of others and will often hold myself in very `Low Esteem'. I further understand that `Extreme Mood Swings' and Phobias, which are quite common following an abortion, as is `Severe Depression', can lead to `Suicide Attempts' and other irrational behavior through `Anguish and Bitterness' over what I have had done which commonly is translated into complete `Hatred of myself': _________ I acknowledge that `Prolonged daily periods of Crying' are to be expected (particularly on Mother's Days and on all Holidays, as well as on anniversaries of termination and projected birth dates) and that when I eventually fall asleep I am apt to have `Horrible and Haunting Nightmares': _________ I understand and acknowledge that "Changes in Hormonal Balance of pregnant women highly intensifies our Emotional sensitivities and reactions" leaving us Unsound in our Decision Making Processes and that the "Courts of the Land" offer no protection for women or even girls in these circumstances: _________ I acknowledge that there have been cases of and that it is possible for me without my knowledge or consent, to have only One Twin Killed. The other remaining alive with possible minor or major injuries from the destroying procedure: _________ I acknowledge that upon extraction and examination of tissue from within me, if it be determined that the pregnancy tests and/or procedures used in determining I was pregnant were in error, and that I was indeed not pregnant, I will still hold harmless the above mentioned organization for any damages incurred. I understand further that such fees, which are to be paid in advance, will not be reimbursed: _________ I do solemnly swear or affirm by all that is Holy to me that I have insurance or sufficient financial resources to pay for all complications which may arise: _________ (I understand that if this is not or comes to be not true I will accept indigent care at whatever government facility is available, if any.) Should death become imminent because of the abortion procedure, I desire to have the following priest, minister or rabbi called: ___________________________________ I understand from all of the above that abortion does not solve problems, instead, abortion is only the beginning of additional and more complex problems: _________ I understand that there are couples who desire to pay my expenses and adopt my baby. I reject them even though they could provide for and love my baby: _________ I understand that I can here and now ask for help, regardless of my age, and receive protection against anyone who is attempting to force or otherwise coerce me into having an abortion, be it boyfriend, husband, parent, pimp or any other person. I solemnly state that I am not under any such pressure and reject legal and all other forms of help which are presently available: ______ I have been informed of the availability of government and other financial aid as well as help in solving other of my problems, but reject such help: _________ I acknowledge that this form has been read with me & has been explained thoroughly to me. With forms in hand I have reread & understood them: _________ Date: ______________19_____ Signature of mother: __________________________ Witnessed by: ______________________ Witnessed by: ______________________ When ordering please specify "Claim Release Form 2" (CR From 2) 
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