(a) Physicians shall use a form created by the Department of Health to obtain the consent required prior to performing an abortion on a pregnant woman.

(b) A form is not valid and consent is not sufficient unless:

(1) A parent or legal guardian initials each page of the form, indicating that he or she has read and understands the information included on that page;

(2) A parent or legal guardian signs the last page of the form in front of a person who is a notary public;

(3) The pregnant woman initials each list of risks and hazards detailed in subdivision (c)(4) of this section;

(4) The pregnant woman signs a consent statement described in subdivision (c)(6) of this section; and

(5) The physician signs a physician declaration described in subdivision (c)(7) of this section.

(c) The form shall include without limitation the following information:

(1) A description of the pregnant woman's rights, including the right to informed consent as granted by the Woman's Right to Know Act of 2001, § 20-16-901 et seq. [repealed]; and the Woman's Right to Know Act of 2015, § 20-16-1701 et seq.;

(2) A description of the parent or legal guardian's rights under state law;

(3) A detailed description of the surgical procedures or medical procedures, or both, that are planned to be performed on the pregnant woman;

(4) A detailed list of the risks and hazards related to the surgical or medical procedures planned for the pregnant woman, including without limitation the following risks and hazards that may occur:

(A) Infection;

(B) Blood clots;

(C) Hemorrhage;

(D) Allergic reactions;

(E) A hole in the uterus or other damage to the uterus;

(F) Sterility;

(G) Injury to the bowel or bladder;

(H) Possible hysterectomy as a result of complication or injury during the procedure;

(I) Failure to remove all products of conception;

(J) Possible continuation of pregnancy;

(K) Cramping of the uterus or pelvic pain;

(L) Cervical laceration;

(M) Incompetent cervix;

(N) Emergency treatment for any complications; or

(O) Death;

(5) A description of additional information that shall be provided by the physician to the pregnant woman under state law;

(6) A consent statement signed by the pregnant woman that includes without limitation the following information individually initialed by the pregnant woman that the pregnant woman:

(A) Understands that the doctor is going to perform an abortion on her that will end her pregnancy and will result in the death of her unborn child;

(B) Is not being forced to have an abortion and that she has the choice not to have the abortion and may withdraw consent prior to the abortion;

(C) Gives permission for the procedure;

(D) Understands that there are risks and hazards that could affect her if she has the planned surgical or medical procedures;

(E) Has been given the opportunity to ask questions about her condition, alternative forms of treatment, risk of nontreatment, the procedures to be used, and the risks and hazards involved;

(F) Has been given information required by statute; and

(G) Has sufficient information to give informed consent;

(7) A physician declaration, signed by the physician, stating that:

(A) The physician or his or her assistant has, as required, explained the procedure and the contents of this form to the pregnant woman and her parent or legal guardian and has answered all questions; and

(B) To the best of the physician's knowledge, the patient and her parent or legal guardian have been adequately informed and have consented to the procedure;

(8) A parental consent statement that states that the signing parent or legal guardian:

(A) Understands that the doctor signing the physician declaration form is going to perform an abortion on the pregnant woman, which will end her pregnancy and result in the death of her unborn child;

(B) Has had the opportunity to read the physician declaration form or have it read to him or her and has initialed each page;

(C) Had the opportunity to ask questions of the physician or the physician's assistant about the information in the physician declaration form and the surgical and medical procedures to be performed on the pregnant woman;

(D) Believes that he or she has sufficient information to give informed consent; and

(E) Affirms by the parent's or legal guardian's signature that he or she is the pregnant woman's father, mother, or legal guardian;

(9) A page for the parent's or legal guardian's signature that shall be notarized by a notary public; and

(10) Any additional information that may be provided to a woman under the laws of this state in order for a physician to obtain her informed consent prior to performing an abortion.