(iv) Prior to the ultrasound, obtain from the pregnant woman a copy of a completed, signed, and dated election form. The election form shall be produced and made available by the department, and shall state as follows: "Ultrasound Before Abortion Notice and Election Form
Louisiana law requires an ultrasound examination prior to the performance of an abortion. By signing below, I certify that I understand the following:
(1) I have the option to look at or look away from the ultrasound display at any time.(2) I have the option to listen to the heartbeat of the unborn child that is required to be made audible unless I decline by initialing here: ________________.(3) I am required by law to hear an oral explanation of the ultrasound images, unless I certify below that I am pregnant due to an act of rape or crime against nature as defined by R.S. 14:89(A)(2).(4) I have the option to ask and receive answers to any questions about the images of the unborn child.(5) I have the option to ask for an ultrasound photographic print depicting the unborn child. __________________________________________
Signature Date
OPTION FOR WOMEN WHO HAVE FILED LAW ENFORCEMENT REPORTS:
I certify that I have reported an act of rape or crime against nature as defined by R.S. 14:89(A)(2) to law enforcement officials, and that I decline to hear an oral explanation of the ultrasound images.
__________________________________________
Signature Date"
(v) Orally read the following statement to the pregnant woman in the ultrasound examination room prior to beginning the ultrasound examination, and certify by signature on a form that shall be produced and made available by the department that the following statement was delivered orally: "During this ultrasound examination, you have the right to an oral explanation of the results. You have the option to view the images on the ultrasound screen. The heartbeat of the unborn child, if present, will be made audible, unless you declined on the election form. You have the right to receive answers to any questions you ask about your ultrasound examination. You have the right to receive an ultrasound photographic print, which will be provided at your request."