The Rose Clinic Self-Referral

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About this Form

The ROSE Clinic (Reproductive Options and Services Clinic) is based at the VG Site of the QEII Health Sciences Centre in Halifax providing surgical and medical abortion. We also help arranging these services closer to home. Our experienced staff can provide accurate information and compassionate counselling.

Patient Information:

Last name

First name

Preferred Name

Prounouns:

Phone

For example, 902-555-5555. If you do not have a working phone number please enter 000-000-0000

Can We Leave a Voicemail?

Yes

Birth Month:

Birth Day

Birth Year

Health Card Number:

Street Address

City/Town/Community

Apartment/Unit

For example, ‘Apt 100’ or ‘Unit 5’

Postal code (no spaces)

For example, B4C3Z1

Primary Language:

Do you need an Interpreter for your visit?

Yes

Your safety is important to us. Please how you move around

Gynecological History

Have you taken a urine pregnancy test?

Yes

Are your periods regular?

Yes

Do you have an IUD inserted presently?

Yes

Are you currently using any other form of birth control?

Yes

If yes, please describe:

How many times have you been pregnant?

How many vaginal deliveries have you had?:

How many C-section deliveries have you had?

Have you ever had an abortion?

Yes

Have you ever had a miscarriage?

Yes

Have you ever had an ectopic or tubal pregnancy?

Yes

What was the first day of your last menstrual period? (YYYY/MM/DD)

If you don't know please use UNKNOWN

If the exact date of your last period is unknown, please provide your best guess (e.g. early December):

Was your last period normal?

Yes

Have you had any tests (blood work, ultrasound) ordered by any other health care providers for this pregnancy?

Yes

Medical History

Height:

Weight

Is your weight in lbs or kg

lbs

Have you ever been told you have MRSA or VRE?

Yes

Have you ever been told you have any of the following:

Asthma

Diabetes

Seizures

Migraines

Heart Disease/Murmur

Anemia

Clotting or Bleeding Disorders

Have you had any surgeries in the past?

Yes

If yes, please describe:

Have you had a reaction to anesthesia?

Yes

Do you have any other medical conditions?

Yes

If yes, please describe:

Do you have any allergies?

Yes

If yes, please list allergies:

Are you taking any medications?

Yes

If yes, please describe:

Do you have any drug coverage/insurance?

Yes

If you are pregnant with more than one fetus, do you want to be notified prior to the abortion?

Yes

Additional Info

You have 5000 characters remaining.

When We Contact

Telephone calls may come from a blocked or unknown number. Please make every effort to answer the phone whenever possible. We will leave a voicemail unless otherwise directed.

I will do my best to answer blocked or unknown numbers

Disclaimer

Once submitted, you will be contacted by a ROSE Clinic team member by phone within three (3) business days between the hours of 8 a.m. and 3 p.m. We are closed on all holidays.

Privacy Note

Nova Scotia Health Authority is committed to protecting the privacy of your personal health information, in accordance with Nova Scotia's Personal Health Information Act. Access to your personal health information is available to those who need to know in order to provide care, including: physicians, nurses, technicians, therapists and other health professionals. They are responsible for following Nova Scotia's Personal Health Information Act. In collecting, using or disclosing your personal health information, we take measures to ensure the privacy and confidentiality of the information is protected in accordance with the Personal Health Information Act. This Privacy Statement provides a brief description of the Nova Scotia Health Authority's practices for the collection, use and disclosure of personal health information. The personal information we collect may include: • Your name • Date of birth • Provincial health card number • Address • Health history • Information about the tests, procedures and care you received We collect personal health information directly from you or from the person acting on your behalf. Sometimes, we ask other health professionals or health care organizations involved in your care for your personal health information. This helps us provide care to you. We may collect personal health information from other sources, if the law allows or with your consent. Personal health information may be collected and stored in different ways. This includes your paper chart, electronic file and images. We use and disclose your personal health information to: • Treat and care for you during your stay or visit • Help other health professionals outside of Nova Scotia Health Authority who are involved in your care to provide health services to you• This could include your family doctor, pharmacist or nursing home staff. • Receive payment from your provincial health care plan, private insurer or other body for delivering care to you. • Support Nova Scotia Health Authority's educational activities• We are a learning organization. • Conduct activities that help us improve the quality of care and patient safety, and manage risk • Conduct patient experience surveys • Conduct research, if you give your express consent. Note: Some research studies do not require your consent. These studies have safeguards in place to protect your privacy under the Personal Health Information Act. This includes review of all studies by a Research Ethics Board. • Give family or friends confirmation that you are in hospital, your room and telephone extension, and general condition (e.g. fair, good) on the day they request the information. • Notify a representative of your faith group so that they can visit during your stay, if you identify your faith group. • Plan and manage our operations. For example, staff scheduling, management of beds, etc. • Enable the provincial Department of Health and Wellness to plan and manage the health system. You may withdraw or withhold your consent for the following uses and disclosures of health information. We will do what we reasonably can to meet your wishes. • Confirmation of your status as a patient. As soon as you are admitted to hospital, please let staff attending to your care know that you want this information kept private. • Use or disclosure to a specific health professional or health organization involved in your care. • Educational activities • Patient experience surveys • Notification of religious representatives (if you have identified your religion) You have the right, subject to some exceptions, to • See and ask for a copy of your health information • Ask us to make corrections to inaccurate or incomplete health information • Ask for an audit on who has accessed your personal health information. • Be told if your information is lost, stolen or shared with someone without authorization. • Change your mind if you have previously given us permission to use or share your health information. You can find information about how to make requests for your personal health information from us on the NSHA home page under Health Information Requests. To learn more about how to access your health information, how we protect your personal health information or to express a concern about privacy and confidentiality, email privacy@nshealth.ca