Province of Nova Scotia

The Rose Clinic Self-Referral

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:

For example, 902-555-5555
For example, ‘Apt 100’ or ‘Unit 5’
For example, B4C3Z1

Gynecological History

If you don't know please use UNKNOWN

Medical History


Once submitted, you will be contacted by a ROSE Clinic team member 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