LeROY H. CARHART, M.D.
ABORTION & CONTRACEPTION CLINIC OF NEBRASKA
1002 West Mission Avenue, Bellevue, Nebraska 68005 (402) 291-4797
STATE OF ______________________) PARENTAL NOTIFICATION AFFIDAVIT
COUNTY OF ____________________)
1. Comes now______________________________________________, who states, under oath, that she/he is the natural parent or court appointed legal guardian of
2.____________________________________ further states, under oath, that she/he has been informed by LeRoy H. Carhart, M.D. that he will perform an abortion upon her/his daughter and she/he is aware that this abortion will terminate their daughter's pregnancy and that the abortion process is not able to be stopped or reversed once the abortion has been started.
Social Security Number: ______________________
NOTARY: I certify that on the ___________ day of _______________ 200___,
________________________________________ appeared before me and completed the above affidavit.