50-20-505. Consent form -- disclosure -- requirements for validity. (1) The department of public health and human services shall create a consent form to be used by physicians, physician assistants, or their agents in obtaining the consent of a parent or legal guardian as required under 50-20-504 or in obtaining the waiver of the consent of a parent or legal guardian as provided for in 50-20-507.

(2) The form must disclose but is not limited to the following:

(a) any information that a physician or physician assistant is required by law to provide to the minor and the rights of the minor;

(b) the rights of the parent or legal guardian;

(c) the surgical or medical procedures that may be performed on the minor;

(d) the risks and hazards related to the procedures planned for the minor, including but not limited to the risks and hazards associated with:

(i) any surgical, medical, or diagnostic procedure, including the potential for infection, blood clots in veins and lungs, hemorrhage, and allergic reactions;

(ii) a surgical abortion, including hemorrhage, uterine perforation or other damage to the uterus, sterility, injury to the bowel or bladder, a potential hysterectomy caused by a complication or injury during the procedure, and the possibility of additional procedures being required because of failure to remove all products of conception;

(iii) a medical or nonsurgical abortion, including hemorrhage, sterility, the continuation of the pregnancy, and the possibility of additional procedures being required because of failure to remove all products of conception; and

(iv) the particular procedure that is planned for the minor, including cramping of the uterus, pelvic pain, infection of the female reproductive organs, cervical laceration, incompetent cervix, and the requirement of emergency treatment for any complications.

(3) The form must include:

(a) a minor consent statement that the minor is required to sign. The minor consent statement must include but is not limited to the following points, each of which must be initialed by the minor:

(i) the minor understands that the physician or physician assistant is going to perform an abortion on the minor and that the abortion will end the minor's pregnancy;

(ii) the minor is not being coerced into having an abortion, the minor has the choice not to have the abortion, and the minor may withdraw consent at any time prior to the abortion;

(iii) the minor consents to the procedure;

(iv) the minor understands the risks and hazards associated with the surgical or medical procedures planned for the minor;

(v) the minor has been provided the opportunity to ask questions about the pregnancy, alternative forms of treatment, the risk of nontreatment, the procedures to be used, and the risks and hazards involved; and

(vi) the minor has sufficient information to give informed consent.

(b) a parental consent statement that a parent or legal guardian is required to sign. The parental consent statement must include but is not limited to the following points, each of which must be initialed by a parent or legal guardian:

(i) the parent or legal guardian understands that the physician or physician assistant who signed the physician declaration statement provided for in subsection (3)(c) is going to perform an abortion on the minor that will end the minor's pregnancy;

(ii) the parent or legal guardian had the opportunity to read the consent form or had the opportunity to have the consent form read to the parent or legal guardian;

(iii) the parent or legal guardian had the opportunity to ask questions of the physician or physician assistant or the agent of the physician or physician assistant regarding the information contained in the consent form and the surgical and medical procedures to be performed on the minor;

(iv) the parent or legal guardian has been provided sufficient information to give informed consent.

(c) a physician declaration that the physician or physician assistant is required to sign, declaring that:

(i) the physician or physician assistant or the agent of the physician or physician assistant explained the procedure and contents of the consent form to the minor and a parent or legal guardian of the minor and answered any questions; and

(ii) to the best of the physician's or physician assistant's knowledge, the minor and a parent or legal guardian of the minor have been adequately informed and have consented to the abortion; and

(d) a signature page for a parent or legal guardian of the minor that must be notarized and that includes an acknowledgment by the parent or legal guardian affirming that the parent or legal guardian is the minor's parent or legal guardian.