Ohio RU486 Event Reports 2012-2016

'
State Medical Board of Ohio

Report of RU-486 Event
(Required pursuant to R.C. 2919.123)
. .... ...
To be completed by the physician who provided RU-486
1. Date RU-486 was provided: / 2- I '3

Month Day Year
2. Name of medical practice or facility at which RU-486 was provided:
Pl ~,,,r1.trf fo.r.{Y>ft100/
3. Address of medical practice or facility at which RU-486 was provided:
23 tL{ ;A-LAhv.r/l /f-v-A. {Anei ' ,I

of-I if~J/7
4. Date post RU-486 complication began:
I~ y/ I'
5. Event(s} {Please check all that apply):
_ Patient hospitalized
~ complete abortion
- Adverse reaction to RU-486
- Patient received a transfusion _ Severe bleeding
_ Other serious event (specify}
6. Duration of event: 3 Hours Days
17. Remarks:
,8. a. Name of physician who provided RU-486
18. b. Physician's signature - ~~ / ~DO

Date--------------------
Send completed forms to: State Medical Board of Ohio

Legal Department
30 E. Broad St., 3rd Floor
MEDICAL BOARD
Columbus, OH 43215-6127
DEC J 7 2016
Prescribed: S//2011 , Rev. 12/13/12
(Requ ired pursuant to R.C. 2919.123)
1. Date RU-486 was provided:

Month Day Vear
P) o.xu1uJ PllY-m +ho cl ~CLS+ S UYi c cc I

3d55 ~as lA-tLi VL S-t
C,o l LA., \pLA.,S 1 0 h t Lf 3 2[ 3
4. Date post RU -486 complication began:
12/u lli>
5. Event(s) (Please check all that apply):
_ Incomplete abortion Adverse reaction to RU -486 _ Patient hospita li zed
Patient received a transfusion _ Severe bleed ing
7. Remarks :
fD/t rtud.J ca.Jrcn ClDJ }-;cn @qwu fh_n.ld . lYC fer rn~o ~v-.j 1uf
OC\ tZ j13J1y .
8. a. Name of physician who provided RU-48/'\ A_= (I no ffiQflO

8. b. Physician's signature "=:b. ~ ~ ~ ~I~ p
Date --==-==----5~-!.::::../~-I-J..-,J; ?j,-4-1-..J./{t.L--(2_

Legal Department
30 E. Broad St., 3rd Floor MEDICAL BOARD
Columbus, OH 43215-6127 DEC 16 201
Prescribed: 5/--/2011, Rev. 12/13/12


II
Month Day Year
Pl trr'lr11'&1 f0ir~Y>~o/
231<-{ ft<A h vi'/, ;A-u-t. (Anc, ' ,;

of/ L-/~Jlj
1~/ 3 I ,~.
~ omplete abortion
- Adverse reaction to RU-486 _ Patient hospitalized
Patient received a transfusion _ Severe bleeding

-
_ Other serious event {specify)
6. Duration of event:
c12- Hours Days
7. Rem~~~:. (
u) - dor-V {/.J, ,.M D~ ,'h~ ~
18. a. Name of physician who provided RU-486 /,v'r-f r

1
8. b. Physician's signature ~ /...___ __ _ _ a ID0
Date l?--/J'/1 J. '

Legal Department
30 E. Broad St., 3rd Floor ...... ,... ... --......
' . ,)
e 01
Prescribed: 5/--/2011, Rev. 12/13/12
. ... ....
To be completed by the physician who provided RU486

JO !Co
Month Day Year
Pl ti'"1r1.f fo.r~Y>fhooJ
3. Address of medical practice or facility at which RU-486 was provided :
23 tL{ ftu b vf/l ft..,u. {An t,t ' .,I

o-fl ~JI?
II I 4'11~
_ Incomp lete abortion

- Adverse reaction to RU-486 _ Patient hospitalized
Patient rece ived a t ransfusion _ Severe bleeding

-
_Lot her serious event (specify} rt~rl 1J11ct "c-CJ/o- Ilk fl, .Dt-.,
,8. a. Name of physician who provided
18. b. Physician's signature

Date P--l~ [\la
Lega l Department
30 E. Broad St., 3 rd Floor
DEC 12 2016
Prescribed: S/-/ 2011 , Rev. 12/13/12
. -:-. '
. .. .. ....
1. Date RU-48 6 w as provided: /0

Month Day Year
fl ei,,, N rl f o.r ..e11f-~~cl

}-S I cf /tu t, t) ( vi ;+v-1' , ~ '/lu'

I
(f, rz.-,q
/ 1) /7-~ //{,,
_ Incomplete abortion
Patient received transfusion _ Severe bleeding

- 2
L other serious event (specify} &drcl ffe cf;(a f-;' 0\, /f, ,/'r) o--
6. Duration of event: ~ Hours Days h,,,. ~ rd:,ry,,-cf7 k ~f'_;,j';,t,-

17. Remarks:
18. a. Name of physician who provided RU-486~~

I
18. b. Physician's signature 0
DatP-iii~

Legal Department
MEDICAL BOARD
Co lumbus, OH 43215-6127
DEC 12 2016
Prescribed: S/-/ 2011 , Rev. 12/13/12
,Report of RU-4~6 Event i
I
I
I
I
1. Date RU-486 was provided: 3
Month Day Year
i
P\~~ Pa..reYt+-hood '
3. Address of medical practice or facility at which RU-486 was pro~ided:
~1..51:5 Ea..s+ ~a.in s~e.,t- 1
Colu...vnl?LLS, OH.lO ll'32J3 i

!
4. Date post RU-486 complication began: l 1/IO/ 1u
5. Event(s) (Please check all that app ly):
~x Incomplete abortion _ Adverse reaction to RU-486

i
L
I
Patient hospital ized
_ Patient received a transfus ion _ Severe bleed ing I

!
i
_ Ot her serious event (specify} --------------:..1________
!
6. Duration of event: _ _ _ _ Hours _ ) _g...____ Days
7. Remar ks: I
I
I
8. a. Name of physician who provided R?r6 ~ /!!.1J mart.OS
8. b. Physician's signature ~ ,Z--- _ @t D O
Date I I
11J;J1y
Send completed forms to: State Medical Board of Ohio J
Legal Department
Columbus, OH 43215-6127 MEDICAL BOARD

NOV 2 5 201
Prescri bed : S/ /2011, Rev. 12/1 3/12
I
.;_:- ~-~\/>-,_ State Medical Board of Ohio

;..,~:_.-.': _u~ ~ ~;:~,
Report of RU-4~6 Event
...\i _J):'~/ i
(Required pursuant to R.C. 2~19.123)

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I
II
II wlL,
Month Day Year
; 1, ;_s f. Cl{(\ Jt ColU#tkr

i
!
_ Incompl ete abortion Adverse reaction to RU-486 II_ Patient hospitalized
Patient received a transfusion _ Severe bleeding I

I
!
/o:he, serious event (specify) ___i.2_,._'/e:_d____M_l__d....._.,c_a_n_ffe'l__A_b_o'rn

__.n __'a-_n_____
6. Duration of event: _ _ _ _ Hours _ _

/_/_Days
7. Remarks:
8. a. Name of physician who provided RU-486
Legal Department
DICAL BG.,-~ , ::)
Prescribed: S/-/2011, Rev. 12/13/12 NOY Jl 201

( :',
1. ,.
Tobetompleted by,the :P,liysfc1ali whofi:>i'ovit!ed :Ro"4s6
1. 6 was:~rovrded:
Year
.2. :dka;I practlce-odadlity atwbich Rl):-486_wasJtrovid_
ed:
~-th~.- oC ~cec\~s- . C?~ .P :

-ed,icaf:, pf actice:cir facility.ahvhlth RU-486:was provided:
. . '7.5 ".b5c:> ~oc~s~ cl.e... \2-o~d .
. _1 se-J~.r c\ .. ~e..i-'\ \i-\-\s o ~<-\ -\ L\-
-4:86: -com:pncatfo.n begaii::
_,ot2,\l~ . .
a-se ch~ckaU-th-~t. apply}-:
Adverse r~a"Ctio11 -t o:RU48"6 Pattent. . .$.ptfaHzed

... ...
. ~. sivere:hleedthg.
. . . . . . .; ..
:_.' it{:. ouf:-attp>ri":_df ever.it:-:.

w ~ .:;.... . : ,. - .- .
. \, : .. . ftours- ..;.............____...... o:ays:... - . .~ ... :' .
7 .- lleni'arks~ M~C "c. L-"c.+-i.or-... d~o-r\-(o~ ~e-r +='D~ ~ ' v\A.e..V"\ 0

n \OS {lb .
~o~'<\os.ed ~,~ 00-~o t' Ai_ ?<'e-4t"f'\c - ~ webkd
d.-v\d
i-~ \-Jo. '- 0"" \ o( 2-l \ l {o ?+- d (di \je\A{ . v..1.e. ll
.~ . ~ ,.. .
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State ~e.dicat B:oarct of,oh}o

Lega.1:.0-eperttnent .
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. . 30-E.,Bro:ad.St;.3"r
~
.
Floor
.
.BOARD
CoiwninliS; OH 43215-6127 .
. Nt'JV 1 6 2016
- - - - -- - -- - - -- -
r -
1 '
.
(ReqiJ_ired,:pursu-irnt.'toAU:. i91'9'.i13}
.
To:be. complefe"rl b.ythe :P,hy,Sfcfari whi:>j>i'oviaed :RIJ..4So.

I
1. 6 wa:s_:provided: 5-e + 2..-0\ \o

Year
.2. N~me of-rn d.ical pracu:ce -or-fadlity a-twbich RLJ:;.486_was provid_ed:
. oC. ~ce:~ \;-e;S- _ 9V\ .O :

. . . . .
-edfoaf pfactke or facilityat-which RU-4-86-was provided:

: ~s -:s5c:> Roe~~~ d-e.- \2-o~c\ .
. 1 se-J ~.r 6 .. ...~\~ \,\-tS . 0 . w\ <-\ \ q . t;
-48-fr-cornp ncatbn began::
~ -;,
-.. . ~..,,. ~ ,
Pc1ttent . ~-pfra-Hied
.- 'tf .
r: ,. . ~
.l j-(
::P.ati~rf.6-e'tef 'eda;tra_ttsf~:s:io.n.. ~. Siver,e:t"feedtng .
....
.: _'. :-:6:,,._..0iJra'tJ!)nifrf
.
" ..
~
e\tel'.):t: ":. _._........._.....: .....
::.-.: :
.. .....
,. Hours _ ., f4--.. :(JaS- -~ . : ..
7.Remarks: f'Ae d,LZ!+,or\ c\o or-\-('oY"" ~r "i="DA y-'2~, ,r-er""\ o~ ,l_1s- l1 ~-

-p+, j ~~,("\os-ed _L.U,+h o~~o,'.4 ff'Q.~V)~ V' 4""'~ .+.v-e2--{-ed
U,) ~ ~4,y"t~+t'OV"' . OV"\ \' \ \":) \ \'tOr ?-\-. ~
:J. '1-~v-l Lv~ ll
.:. .. ... . .--4;~~.'?J? .._ ' . ,.
-8. a. f:'"Jame of hysidan who:pr.ovtded RU-486
. ft'h. Physle-faif S' si.grta:f-G=te .
-~3-:. : _ .
State_. Wle:dica-1..Boarti" of:Ohio:

,: .
l:eg-af oeptirttfre.nt .
.. . . .. . . . . a . ..
30 'E., Brcra.dSt, .. 3r Floor ._.
cai-omthis; rnit 43215-6127 .
. .NOV 1 Z015
. .. ..
. PresctTb~i:I: 5/.--.:/ib:i.1' :Rev:"i2/if1i
. . . . . . . .f .
.
. -M
.'ta.te:
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- :-eu1:c:_ a1l,:['o- -~ o'f 'Av. .lrro
),.o:a-ru: ..
..
j;
.Re1P9tt Qf: RUt--486 > erJt

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1
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1-:
! .
To:b'ec6mplefed b.ythe:P,hv:src1an.who:proviffed-Jt0..4sG
Oc...t __ )-
Mor.1th Year
dica:I practice o dadlity atwbich RU-486_was provid_ed:
>: ~~~~-- .ck. -~ cec\-~r _C?V\ o

-<
ed kal'. j:rr-acti'ce :6r facili-t y.atWhleh RU-4-86:wa-s provided:

_ .:Zs-:s5~ R c~s~ cl.e.- '2-.o~c\
0 .
. '\s.e.J ~ -i 6 . .-~i~ \r\-tS. .0 . W\ <-\ \ L\ 11
. : \0
a-se check,aJ1th-~t.-apply)..:
.Advers:e r~action -tro:RU-'48-6 Pi:itlent. . .{ptfaHzed

."'""
. .. ,: . ~ .. .
7_.Rentarks:
.~ ,_. .- . ..:. . :- . ... r
'." 8:, a. Nar6Efo"f'.i "'hV-sidanwho;pr:ovro.ed RU-486 -- ~
. -_ g:h. Pl1Y,S-i'tiaf.f S'.si:grtatb'te .
._. - .,,.:. r.-:- : ...
State Wle:dica-L.B'oard ofOhTo:

heg:af De Pei rtrfre.nt.
30 1:.,Brottd. St.; .3'r=FloO'r _ .- . . ...
C-okmibus; OH
.
43215-6127 .
.
M!Ol(;AJ. PO . \r_
~
NOV 15 ~Ci
. .
- --.. .
.
...... .' '::~i/::~i .
" .,..
. \ $i:J<. . (Requ ired pursua nt to R.C. 2919.123)
. .. .. . .......
;~
To b~ completed by the physician who provided RU-486
1. Date RU-486 was provided: /0

Mont h Day Year
2. Name of medical practice or facility at which RU-486 was provided: NORTHEAST OHIO WOMENS CENTER
LLC
2127 STATE RD
NORTHEAST OHIO WOME
3. Address of medical practice or facility at whtt:~~~i~$ti RCJlS provided:
CUYA._
HOGA FALLS, OH 44223
4. Date post l~i.J~ ?Ccation began:
I I
5. Event(s) (Please check all th~t apply):
_ Adverse reaction to RU-486 _ Patient hospitalized
_ Patient received a transfusion _ Severe bleeding
_ Other serious event (specify) - - - - - - - - - - - - - - - - - - - - - -
6. Duration of event: __{_ _ Hours ____ Days
8. a. N'ame of physician who provi
Send compreted forms to: : State Medical Board of Oh io

Lega l Department
Prescri bed : 5/--/2011, Rev. 12/ 13/ 12

(Required pursuant to R.C. 2919.123}
........ .
1. Date RU-486 was provided: /D 14'

Month Day Year
~5 ll/ ./1-ubur..-, /fw ,

;o/1~ /;l:,
--Plncomplete abortion - Adverse reaction to RU-486

-
18. a. Name of p hysi cia n who provided RU-486 --:---_D

__._,_ _.../r..-.;;,!.1...;~c/c.
""------- - - - - - -
8. b. Physician's signature ~~ @o a
DateCTJo /'-bfa,
Legal Department
MEDICAL BOARD
Columbus, OH 43215-6127 VO 7 2016
Prescribed: 5/--/2011 , Rev. 12/13/12

.
..:fl~::=:~~~,~:;~;f::~ilt.
.
: lRe~ufred;pursaa'ri:t;to..R1C. igi~.1:J~)'- .
ro:b:e:col'Tlphfted.b,ythe:~1{1:fsfclan'whoj,ro\ifoed:Jio4s6-.. .
:4
. . .. ~ : : . .,,: ... : , ..
Year
. - . . . .
.2.- :N~:me oftn-e:d.i'cal _pr.actice -~r-fac:fHty at.which RU~48-6 wasJ1rovided:

. . t...' . . . . . ' ~ . .. . . .
:.c k., ~~~\2:r . _qV\iv.<?.. . ~ .

. _:>:.._...o.<~*-h~.--~ ' :,:,,I. ... ,,o , , , :, t !, - w " - ' ' " '' : - , ~
. <3, Address;i it me:dfo~at:p,f~cti'te. _.trrfaciHty,.-~t<Whkh RU-486--~was-provided:

. . . . . . . : . . . ~ s ~5c:> }2.. oc~s~ cl.e.. . \2-0~d . .
. . .
'. - <~~~~--~ _i6'.~e:.t~_\r\-\-s. :_-9 . . ~<-\1L\_~ ,.. ,:.>.
4. -6at~::.p'Gst _
J{;U-4}:lfrco'f;pltcatfo.n bega.n::
. ._ ,. .. . , . ... ..: ..
: :S .' EVeht(:s-)::1(:Plea,s.
.
e ch~k,a'H
' . .
. tf'.$.t_.a:pplyt:
.: ..
..- . ,.
.. v'intbh\plet~~::ibor~fdh;:-_: .. : .... _._. 'Pc1tterit_. ~0-$.pff.~1-ried

. _
.. I/! .
~ -;.: .' ~ : P.ali~~ti~t~ivefl ait~arts.~:5.1tiri,.,:..::/,.~.->Sey.er.e::o.reedth-g- .

LY~ ... . . .
~- . . ;
: :::.:,t~tf.\(s:ci/i_o:us,e.v~~t:t#;~.21i.v.}: ...... ._______. ;. . . .;.__..,. =--' -;o---..;..:...;..;.....;..;,;.,.__ _..........;_..;._:...,,

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. ;...
...... :. a;--. ; =--- .......---- ......_.
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.. . . . ~ ' . -:;_ . . . :.": : . :
_.. <6,. . 9~f:-af)9~:.~i--event: , . ... . _\ .... flours. _ . .:>-. .-. .. . _(lays:

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.,:. , ,j....: :.,:. ...:. -~ :.. ~~ .:. . : 1.- ,,'-' . ::. , :- . .. .<. . ... ... .~ :; ... . . .. . .. , . :. .
Me-A<c~{-ior"' ~loor+(~~ f-~v' F ,D.A- r.e) f. ~VI o- l f ~{.(la .

'7.Re,niarks~
'P\-: .d; r~os-ed v-,t
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_o V\ c;o\ V")
-~c;.f ; :vc -h'o"' oV" , ( z.1 fl~ .
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pr-e cJ v" o-_~ c.~ :. + +v-e,~-kd .
-p~ ct d. . ve Vl-1 lJ..) e {
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..... -..... ..:.>.,. :. p.9s.t::.~eP..;~,, . . . . - . . .... . ---- .-.. .. , '. ' . :-. " . ,' .. :~ . ~""
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:_-_--:,-,G ~ - ..- .....-~ . .D,,0 -
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--~~ . , ~ .- ....,~:.... f .:j' .~. _.... .
State-:_. Me:..dica-1 ..Btrari:l' of:Qhfo:

. . . . . .
tega-f:.'.o:epa.rtm-~nt .. -
::_:-.30.t., Br:ottd.St..;. .3"0 Fl~or- _ ....
. 'MEDICAL BO .
..Cohlrnbirs:t .o~ 4-3215-6-127... .
-~-
.OCT . 3 1 .201 . ..
r -
\ ..
. .
. .:{Re~u.ire-ci':._t;rurso.a'ntito.- RJt . 19.t~.12:~y. ..

T{fbe coltlptefot! b.1/theiH~:src1an who;provttfedJio:..risf.
. .. . :,: ,: .
Year
.2.- ' N~me of-medrcal pra"Ctite-odacility at wbich RU;.486 wasJ>rovided:
. . 1?)?.if.\"'e;\.:. :.~~<~~~-- :. oC , -~ re-c~~r . qyyi~_<;r-~
.. -3 , AddreSS~:b{ rnedit:at:-r.tf~c~ce .:tfrfadllty,. ahvhith RU-4'86:was -provided:
.. . .. . . . . . -~ s ":3>5c:> Roc~Si cl.e.... \2....0~d . ..
.
.:..
.
._: ~ :~~-~ ._rJ -- \-\-'~i~\n.~ ---a.~ ~<..\ -\~-. ~ .:- ....
4. Dat~:_p'ost :~U-4'8:fr-co'~:t:>'ntatton began:: .
-.- : . : ,: ...
. ~ \ ~ . \ \ lo . .,. ,: .
.
., ;.,
.. . . """-:.~..,. .,._.: '
. . Vinto~plei~~bortfbty\ , . . . . _ -_. .A-cfoers:e r~actioh -to~RU ..48 _ ._. P~tteht.- hc~jjfh1li ted
. _.. \/1
. .._:_- . . ::, .
~
. '. i : : . :- ~-: , . . :, .
-- . -::. ....
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. . 'ti.:l\itlf'.5~~fffifeve~;:..:_._.-_ .. . .-.:._.:...;'. .,;;_.; H.our:S: ........... - __........ :[Jays: .. ..,. ', .- . ...
-< .. ......... : . . ... ~- .. . . .
7 .- l{entarks>
t~ ~.e."' ~ ~ :d .\J" -v"'1 'v...., () ll ,=> o~ \- ~sr1~ \f'c t-,.::v\.
: . . ~.
. - .~ . . . -
.:. . . .... .. . .. - . . = -~. -~: :. :; .. . . . . .. .. :~-::..... .. . . ~- : .... -
. .
. ..._. __ ,.;.,J ::.. :...- . ...._ :-. :. ...:.. - . . _ ~: ~ ..
State:_to/.le:dica-l...Rtran:1.of,Qhfo:
tetaro:e-pt:i.mn~ent ..
r~,: MED~C.AJ_. aoARD

OCT -31 20t6 . ;_ .
. ~
State Medical Boara of Ohio
I

I
I

I
..
To be completed by the physician who p~ovlded RU-486
3. Address of medical practice or facility at which RU-486 was pro1ided:
~[/c;<; G, l'\dlf\ X ~{)\ 11W1kus1 l1\- ~20

,I
5. Event(s) (Please check all that apply): v

i
!
~ mplete abortion _ Adverse reaction to RU-486 II_ Patient hospitalized
MEDICAL BOARD
_ Patient received a transfusion _ Severe bleeding I!
I
i OCT 1 7 2016
_ Other ser ious event (specify) - - - - - - - - - - - - -': . . . . - - - - - - - - -
6. Duration of event: _ _ _ _ Hours _ _ _ Days
7. Remarks:
Ii'\ cm.plo.Je frl tb rtCf W V.Qd
8. a. Name of physician who provided RU-486 :f-.. I 66'. I r!totu >~ Z>
8. b. Physician's signature 6
Date _ _ r ---+-E--=--_t-+--
o~ -_--I-~~- - -
Legal Department
Prescribed : 5/ --/2011, Rev. 12/13/ 12

.........
To be completed by the physician who provided RU-4&6

Il J(p
Month Day Year
P!av1Y11cf far-<~1fv:>.,j SD r..A.,t!_ -t.- ~ DJ. ,' u

~61 t.f /fub~ r~ ;Aw, U/lu~; o1f- Lf ~2 J q

q/ II II~
_ Incomp lete abortion Adverse reaction to RU-486 _ Patient hospitalized

-

-
L Other serious event {specify) ~ / ( cf /ft;, off/ ?r'l C9 mt'./dt'cf' < o/rc;.,/,teg- .
6. Duration of event: Hours Days
17. Remarks
js. a. Name of physician who provided RU-486

I
Date _ _ _ _ _/V--1..{__;_
Lf..L.. / (o
/ !.....::::;..___ _ _ _ _ __

Legal Department
MEDICAL BOARD
Columbus, OH 43215-6127 OCT 11 2016
Prescribed: S/--/2011 , Rev. 12/13/12


Month Day Year
PI~~ .ed far~

VJ c-Q ~o c.<., fh tr-'--t' ~+- ()i, ; o
)s1Lf ;,fuf>vr"" /hr<) a, u 'r, ,-ce -1r.:,

11 off ff ~1, I t
C}/;S-/1~
-2Patient received a transfusion ! { !severe bleeding
_ Other serious event (specify)
6. Duration of event: ~ Hours Days (f}ill~ -,, IY'( V) ctZ 'b,r 1-rY:+~~4 ~ )
17. Remarks:
~
I
8. b. Physician's signature MDtDO
Date _ _ _/ o
____A_ttJ_1___
(p_ _ _ _ _ _ __

Legal Department
MEDICAL BOARD
OCT 11 2016
Prescribed: S//2011, Rev. 12/13/12
Report of RU-486 Event MEDICAL BOARD
(Required pursuant to R.C. 2919.123) SEP 23 2016
..... ....
1. Date RU-486 was provided: g lb l&

Month Day Year
Pf eiv, ~ d for tvvfh a of! ~v11h~ Oh JD ? c; [Q~

(}
)~ I '-I ;1-l/lburn ,4-zH r u>)u'r>~' / oll //~.t2--1?

9/30 /(~
~ complete abortion

-
6. Duration of event: Ci) Hours Days
17. Remab ~ ( J "'1"1' ~ ,'(h cPA

I
18. a. Name of physician who provided

r b. Physician's signature
RU-486 g:tzt- ,.Sa~ l.,
MD /0 0
q/J-o
r
Ilk I

Legal Department
Prescribed: S/-/2011 , Rev. 12/13/12

(Required pursuant to R.C. 2919 .123)
To be completed by the physician who provided RU -486

D? / {2
Month Da y Yea r
{Jte_J...r IN\.
4 . Date post RU-486 complication began:

t)~ /1 /;~
5. Event{s) {Please check al ( thaf ap~ly):
~ m plete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify) - - - - - - - - - - - - - - - - - - - - - - -
6. Duration of event: _ ..... a~-- Hours _ ___ Days
7. Remarks:
8. b. Physician 's signature - -;#-(1/).

.;.._pVJ
-fr-4f-7,=~'--f7'~~ ~~<?c,,c------~~~~~ouO..L--
Date v% s r!G
Send completed forms to: State Medica l Board of Ohio
Lega l Department
MEDICAL BOARD
Prescribed: 5/ --/2Gf1, Re v. 12/13/12
SEP 6 2016
_.., _.,>
... ~

(Requ ired pursuant to R.C. 2919 .123}

87
Month Year
Ae,Jo-~
3. Address of medica l practice or facility at which RU-486 was provided:
~ comp lete abortion Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify) - - - - - - - - - - - - - - - - - - - - - - - -
6. Duration of event: ---"/_ _ Hours _ _ __ Days
7. Remarks:
8. b. Physician ' s signature
Send completed fo rms to : State Medica l Board of Ohio
Lega l Department
MEDICAL BOARD
Prescribed : 5/ --/2~ ~1, Rev. 12/13/ 12
SEP 6 20
-
r - .
\. ..
iredJ;>urso-a'n:f to.-itt. igj;~.11~)
{R-eqi.J_
Ttf bl! complete"d bythe,P,h9sfcian.who;provitfedJt0..4S{t ..

1. :bat-e.-RH-486 Wa:SJJrOVrded:
\
Y~ar
ce-orfadlity abwhich RU-486_was prov!ded:

_2.- N9me9frne:d.ica:1pracu_
._ ..-~ -~~~~-- ~: ck. ~ce~\?-s- . q\r\_:~_q

3 , Addre-ss~:0 f med-i<;-akpiactit:-e :6r facili-ty-at,wliith RU-4-86---was -provided:
.. .. . ~s ~5c, J-e..- ~O~d
Roe'<.-~~ _
_1se-J~-,,.~ - -~~i~~+; o w\'-\\q.c,o . 11
. .
4. Date post frU-48-fr-cbrtrpncatfon begah:: . .
-co \nt'l,~
s. Event(sY(Pleas.e che-ckaU-.th-~t-apply}: .. ~;,
i....;. _~ ..,... ~.. r
.0tcbm-~lete-~bottfo~:-~: .:_> .. -.:.:._. .. .
Advers:e re-~rction -to~RU..-48-6 _ .. Piftfent ho~pitaH-zed
._.. \/!
., , . ~ : . ... . .
_
7.Remarks~
_k, t>; rc---8 O"-. ..(:,,, r Ovl :- "\ o [ \ p,..,, ") .--, ? A ~
~\\o~,~ - ~e-6 ' ~~o" ~Coo ,-h'<::>v1
Narn'~:, ot;physi:ci~mwho.J)r.ovtd:ed RU-486

.::: K, a. . L W\.otv\';:1 :- $ .- . . \4-.ce.s.s\: A,A6
. .. . . L/ \ --
.g:6. Ph\[sitiaH'S'sign:a.tfr~e . .... .. \ (.J...,l ~ . ~ ~ O,b . . .
.Date ______ - \~S:~\.-1---

q .1-i..1,\~ _lc;~;;;._- ---~_.__......;..-~:.. ~-:. ..............;..
- .................;,__,;,.;;....;.;.____:.,__:..
:.. .,.. ;.::-.
.State Wle:dical.Boarct of'Ohio

l:ega(.[}e pamn:e.nt.
. . .
- ~o - . . . . ra- . . . . ' .
-E.i.Br:oad St.; ..3 -Floor . MEotcAL .B-OARD
Co i=omhus, 0~ 43215-6127
SEP t' 9.201
. . State:Medi-cal <Boar-.. of . ~: hto
r. ,. .. .tre90:tt<1f' :'R.tJ~'4 : GEfeut .

. . .
\
{Ret1uired-J>ursi.fanH0Jt,C. ig _.11~)-
Ttfbe.c6mp1eted b.'{the:~hy.sfclan.whoj>r
=
-i-.o,
,<.~
Year
2.- N.;:rme o.f-rned.ca:I practice o dadlity at which fm;.486_was prov.id -cl:
-~~~-- . oC.. -~ <'ec~~
3 . Actdr~ stof me.- ,ita'kpfactit:e::6rfacill-tyatWhith RU-4-86::was -prov 1ed:

. . --z.s ~5<:::> Roc~4$\'. k ~o~d .
._1se.J ~ - -r c\ .. \-\,--e-t" \r\-\s-
. . . . . ,.
.0
. _.;_ ,....... -.
,-.--
Advers:e r~~rctio:h to::RU--4"86 .. Pc1tferi.:ho~pfr~lfaed

._.. \/1
. . . '
. _.. -:_.- .S~vere:bleedth'g- .
.. ,. .
.' , ,I. ~ .,
. -- . ,:
------....
-,.......
,_. Hour:s- . ; _'5" O:ays
f\-4 ~ ec.+.t'"'
-k)nov./ ' ~
tm-s.to: State--. Me:dical...B:oa,rd ofDhTo:

-.:- . . .. _
t:egaf.o-e partrtle.nt.
.... . . . . . a .. MEDICAL _
BOAR))
.. ;_. _ 30-'E., Broad.St, ..3r floor
. cotomi:hrs; 0 ~ 432:rS-6l2"i .SEP_1 9 2or
.. . . State Medka:lBoar~ of hto
p ,.
.< Rep:o:t t :a.if: :.l\t.l[;;.'4 ..i EI'ent .
. . .
\ <
{Require-dJ>ursuanHo.:R~t. ig .-_ .12~)
T,;: be c6mpl"efen. b.ythe~~hy-sfclan.whifp r
,,
A ~-
Vear
_. 2.- N~rme ofrne:d ca:I pracu_ce o rfadlity a-twbich RU;.486_was prov.id d:
_ of. :~ ~c\e
3. Add re s0f me ical J'.Jractice or facility at-which RU-486was prov I ed:
.:.Z.s~5c:> Roc~s~ cl.e... ~o~d I[
.\S~~~ i 6 . \.\--e:i~ \,\-\s_ 0 #<-\ \L\
-S-frcofopR:catfon b-egan::
'S ~ -~ :
--:.~~
-. -;.
.,....,:'
. P.:1tten -ho$.pitalfaed
""'
:~ qthr_: :(f~io):JS:e. ~nt:-(:spedfy) :.....-._. ...;;._._____....,....._ _.....;.;...;;..........,_____;......;.._____-+-......._.__._..........,_.

. -~ I
l .. : i - - - - t -_-__ . ---+-------------......---............... --+-+-
. ,-~ - - - - - - - - - - - - - - - - - - - - - - - - - - - ~
.; ... -_. . : ___. _-=. .....

, .. Hours, _. __ :_f\__. . . . :D:~rys.-
~ ( ' 1' rc,4-tc;v, fo< S \ ~ u.J l ""\
\-e,,<.J_G, \s . ~ \ l o ~ ' ~
:: R,:a.~ Na . '~:-.61:\ih,.s"ici-an:w.ho:-llrovtded RU-4"86

_._-~
Statefl.?le:rJica1,Boarct ofOhfo . I
-: . . ...
. t:egar.o:epa.n:m:ent .
_
. . . . . .
.. .. . . . . , . . . ct . -MEDICAL BOARD .
. .: ..... .. 30-'E., Br6ad.St., ..3r Floor
C6i:omhl1s; oA 432:tS-6-127
_._S~ate::Aled1:ca1t-'.89:a r -. of.:-_
:'..-11;_
'.o
... .Re,rott:0.f ,RlJ~4: :5.E/S:rt.t .
r. -.
\
:t
2.0\
Molilth Y~ar
.2. N;rme of med cal practjce orfaci1ity ai:wbich RU-48~_~as providftd: _..
. .
. . . ,A
~ , .. ~ .
.
.
. .
..
. ~ ,r,., d'""I~__,...
. .. ~ .... . c..,,"'
-~
: r .. ~
.l -. . 0\- F (', ?-
~, { e.lt- a ..
, 1. ....
3 . Add re
.
;of me
. .

icat practice o r facility at-which RU-4-86.was prov died;
.:.Z_s ~5<::> Roc~Si d.e.- t;2_o~ ~
. ~~J-~ -r c:\ . -\-\.--G-l~ \,\-\s_ 0
il_<-\ \ q
. .
. 4. -D-ate. ..p-st RU- 8-frcoh;rpncat+on

.
began::
,~
. P~tteh.. ho$.p.ffalfaed
""'
nt:-::: .. _._, '\ .'. , . ~.o urs, __. ............._ .......:D-ays
7. Remar 't\.~f ;<o,+(on {.or OY"-~.'~ I ~9

f,o\\c~""'~ \fY\.~ c\te,~ o~ ~~ r-\,'
: . . . . . .~-- I"
'~_.ot plt .s-ici-a_nw.hoipr.ovtq_ed

g:h. .Phy rc.fa:f:f' s=
... -~. ,-., . -
State,. tvle:dica-LBoarci- of'Ohfo:

. l::egaf..o.-epa.rtrt\ent .
3.0 E. Bro:ad. St..,.3" Floor . MEDICAL_BO.ARD -
r\ .
i_
coi=umfirs; OF! 43215-6127 . SEP 19 2016
PieStih>ed; S/ 1:ioilRe ;il/13/ff I

I
.. t.
p -.,
1. ' ..
,,
. ?.f) .
Moliltfi' ,,: Year
.. . . .. . . . . .
.L Nil-me of r'ned cal practice orfaci1 ity at wbith RU-486_was provid :d:
..'' < .~ ~ ~ ~. : oC ~ rec\e:
. '3. Addr~ s/bf me' ,ical~pf.;ctice 6 rfacillty-aHvlHch RU-4-86:was prov Jed:
. .-. :... . . ...:z.s:;5c, . Roc~s~ <l~ "2-.o~~ 11
. . . . . '\se.J.~.rd-
. .
....~i~ \r\..\s
...._ .- _.
_ . . .- .
.o <-\ \q I!'
'86-coh~i:pn:catfon began;:
. . <B .(?-'-t \ \ ~
f P~tten
11 .~ '8
,.ho'~:p'ffa1faed
.
I . . .
. I
. _____...:D:a.ys
. ,..-..-._,----......... Hours, ____._:_5 .._ .:I. .
~<:>y ' ce---h'Or\ ~.r- o_v"-~ O\

~ \~\JV v\.~ . -N'--e.(\ ' ~~Ot'"'\
.~' ... .
<g~:a.. Na . '~:,. of rif.c.s'idan-.whoj )rovto.ed RU-486
. ~
. .
State ~ e:tjka-LBoarctcf'Ohfo:
. .
-.:.-. _ .... _.
Legaf .oepa.rtt1ient.
.. .-:so.t.,Br6ad.st.,..3"0 -F:roor . MErncAf. BoARD
..Ccih:m5firs:, o ~r 4 32 !5-6-12'7 .
I SEP 19 2016
J
.. I .
. r.
. .. StateMet11cat. B0ar~ of ,Mo .
l~tt :_c,f, RU;. .4
(R-equired J)ursciantito . . R1C. ?9 ..113}
/i E/ent . :-
To:be. con-rpl"efed b.y:theI~hy,Sfcian.who;-pr
.,
?-,0 \
Year
3 . Ad drE:!

.
;_of me

ical ;r.rractice or facility at-which RU-4-86.was prov Idled;
-ZS 35<::> 12.-oc~S\'. J.e,. ~o~d
1s~J.~ .r 6 ~e-:\"' \.-\-\s_ _o "
il
.I <-\\ q t1-
'86:compncatfon began;:
.-,. ~
~ -;;
.i...;. :.~ .,... ..... ,
Adverse r~~rction .to~RU--486 . P~tten :ho$.pfr~tfied

""'
n. t > .. .:. .-.:..,. 1.nour:s-

,.;- . . .:..{O
-1 _:o -ays
. :.- .- \
. 7..Remar . k( <t-+-,Ov""\ -lo < ""'on- v,a~

~ \\ o~r""'5 ~t~~d~
.~ , - .. ' .
State. Wle:dica-LB.oan:l of'OhTo

-.- ..
l::ega-1 )):e parttr.fent .
: .: JO.'E., Bro:ad.'St;;.;.3" Floor
:. . _: 'MEDICAL BOARD : . . . :
coh1riihus; o iir 432:ts-G-12t SEP 19.2015
. . Presctibei:l: SJ i.,t oh,<Re ; :i2/~j /1i

'
/b
Month Day Year
1)\ 0 - 0 ~ v ~ooc:\

q jLt>(Uo
5. Event(s} (Please check all that app ly):
~omplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Patient received a transfusion _ Severe bleed ing
_ Other serious event (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _J_ _ _ _ _ _ _ __
6. Duration of event: _ _ _ _ Hours _ _ _ _ Days
8. a. Name of phys ician who provided RU-486 _ L_i_.s_P\..._...._!(i_e__~- - - - - - - - - - - - - - - - - -

8. b. Physician's signature ~~ i ~DO
Legal Department

MEDICAL Bu ARD
SEP 19 2016
Prescribed : 5/--/2011, Rev. 12/13/12
State Medical Boara of Ohio
I
Report of RU-4~6 Event i
(Requ ired pursuant to R.C. 29 19.123)

I
I
To be completed by the physician who provided RU-4&6
A\,(.flt).~1 I
I
1. Date RU-486 was provided :
lto AO} l.o
Mo I
I
Day Yea r
2. Name of medical practice or facility at wh ich RU-486 was provided :

I
??G-o \.t I
I
- ~ ... o nARIJ
MEUlL-f"\..LI -- -
3. Address of med ica l practice or facility at which RU-486 was provided:
32-5 5 L.J . M~n S 1 I AUG 19 20\6
Co {t.,LV'Vl YJ K ~ , Oft 43~\ 3
I
i
I

il N[ ivtt,
5. Event(s) {Please check all that apply) : Ii
!
_ In co m plete abortion Adverse reaction to RU -486 Patient hospita li zed

- i_. _
iI
Pati ent received a t ransfusion _ Severe bleed ing

I
-
I
i
15_ Other se rious eve nt (specify ) Fa,l<q(. ~c.uf a. 4' Dv ~IV\A.
!
6. Duration of event : z Hours Days
7 . Remarks :
Surq, w co~fl{,,hwt t,{-- o.~Nhwv
8. b. Physician's signature /2?;~ I MD/DO

( Date ____ Bk_~~-~~~.,_________
Send comp leted forms to : State Medical Board of Ohio \
Lega l Department
Presc ri bed : S// 2011, Rev. 12/ 13/1 2

1. Date RU-486 was provided: I (p

Month Day Year

c.nii71 f?ir~,r+h~I) ~0~ f/'J~ o-t;TD - m Lor-
/l 2 I '-( /t-i1 b<A r"' ;A-vt.

r;, ~ r)V) n& 1-.' D+f I
c.f f"?-- (1
~/Cj /1~
MEDICAL BOA RD
_ Incomp lete abortion Adverse reaction to RU-486 _ Patient hospitalized
-
AUG 12 2016
-
0 t her sr' event (specify) Fc::u/~ A,7 (J)~el1f(Jl

l
bJ., ~~ '1.,1rr '"r
6. Duration of event: l Hours Days
17. Remarks:
18. a. Name of physician who provided RU~ - - -_ _ ._c:

__ . ,. S:h::Q:Ao-=-=V"'\;...,..J..._l-.._....:.f'-'_(_ _ _ _ _ _ _ __
8. b. Physician's signature #= M D j DO
.
1
Date rf~/(l
/ Legal Department
Prescribed: 5/--/2011, Rev. 12/13/12

(Required pursuant to R.C. 291~.123)
1. Date RU-486 was provided: ,WJ{e

. Day Year

' \' '
~ Incomplete abortion
.
Adverse reaction to RU-486
-- _ Patient hospitalized
6. Duration of event: ~ - Hours - - - - Days

---
7. Remarks:
8.' b. Physician 1 s signature { m.1:: -

v_ =i_ MD/DO

Legal Department
MEDICAL Bo
Columbus, OH 43215-6127 JUL 18 20f
Prescribed: 5/--/2011, Rev. 12/13/12

. . ... ~ .......,~. .

Month
11 Day
lip
Year
2. Name of medical practice or facility at wh ich RU-486 was provided:
~ r-d-.u-w-..
3. Address of medical practice or facility at which RU -486 was provided:
IJO!ID CA~vdo--i
I
{
5. Event(s) {Please check all that apply):
.-6complete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

-----------------------
6. Duration of event: _ __.2"'"
......___ Hours ____ Days
7. Remarks:
8. b. Physician 's signature
Legal Department
Columbus, OH 43215-6 127 D1CALBOARD
JUL 12 2016
Prescribed : 5/ --/2~1, Rev . 12/13/ 12
.. ':,.- :./Y;J.
. ,.

Day Year
2.
5. Event{s) (Please check all that apply): MEDIC
Adverse reaction to RU-486 _ F4Y~ti !pft2~~ed
6. Duration of event: _ __.....___ Hours ----
Legal Department
Prescribed : 5/--/2011, Rev. 12/ 13/ 12


to
Month [?ay . Year
!:{)ff~ 0 W.\f\ '7\-.

\~ L~
5. Event(s} (Please check all that apply}:
_ / incomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify} - - - - - - - - - - - - - - - - - - - - - -
6. Duration of event: - - - - Hours - - - - Days
7. Remarks: ~ \<tel 0)ed..iC~Cr\ ~Cf)

s\_p l) ~C.,
8. a. Name of physician who provided RU-486 - ---5 ? 3 0tvN~ '['{)
8.' b. Physician's signature Q._,J:::- ==:}_ ~ -0 0_

Date l' 0/ JS {let
Se-nd completed forms to: State Medical Board of Ohio
Legal Department
MEDICAL BO
Columbus, OH 43215-6127 JUN 1 7 2016
Prescribed : 5/--/2011, Rev. 12/13/12

(Required pursuant to R.C. 291~.123)

1.cv) fo
Month Qay Year
2.

. --
~omplete abortion Adverse reaction to RU-486 _ Patient hospitalized

MEDICAL BOARD
JUN 13 2016
-----------------------
6. Duration of event: . l,:( Hours ____ Days
7.Remarks: Jr'\t!dnpleJe.. t'icp(,l,Lstc..n l>f PDC... dw.. to

S,t,ULf-e. ~b r'\ ; cl u.J f-Y\>J:::, .
8. a. Name of physician who provided?:!: ~ Co1htril'l. (l,~~-
8. b. Physician's signature ~:-te-~<=~~=~

-------~--~---=-+-1-~Yi~l./J~-----
Se,nd completed forms to: State Medical Board of Ohio
Legal Department
Prescribed: 5/--/2011, Rev. 12/13/12

(Requ ired pursuant to R.C. 2919 .123)

Month Day Ye ar
l~O'DD D
5//J
5. Event{s) {Please check all that apply):
_6n'complete abortion Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify) - - - - - - - - -- -------------
6. Duration of event: _ _ _ _ Hours _ ___ Days
Send completed form s to:
Lega l Department
MEDICAL BOARD
Prescribed : 5/ --/2~1 , Rev. 12/13/12 JUN 6 2016


Day Year
2. Name of medical practice or facility at which RU-486_was provided:
- 5. Ev/t(s} ( leas check all that apply}: . _
_v(
_ lnrcno mplete abortion
1 Adverse reaction to RU-486 _ Patient hospitalized

-----------------------
7. Remarks:
8.' b. Physician's signature --;(.,rt:

.___~_)+"0~ ..:.;
c:::--------------'r,.~,1"""0.J.....1./-1.D~0,1..__
'o_/t_~_1_f_
Date _ _ (/ _ _ _ _ _ _ _ ___.__ _ __

Legal Department
MAY 2 7 201
Prescribed: 5/--/2011, Rev. 12/13/12


Z23 ,30 ~(J/0
Month Day Year
-A t ~-+ ci"' IN',.
I D
__6n'complete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: ___ 3=---- Hours _ ___ Days
Send completed forms to:
Legal Department
MEDICAL BOARD
MAY 2 2016
Prescribed: 5/--/2~1, Rev . 12/13/12
(Required pursuant to R.C. 291~,P23)
To be com pleted by the physician who provided RU-486

Year
1;iss ~- Yvlvt.lfl St~ ColuvnkMs Q)lf t-J 3v0
l\ hl/ I\1o
5. Event{s} {Please check all that apply}: ,, .
>;,( Incomplete abortion ~(.? \1-o - Adverse reaction to RU-486

- _ Patient hospitalized
1
- Patient received a transfusion /s:vere bleeding

.
8.' b. Physician's signature
Send completed forms to: State M edical Board of Ohio

Legal Department
30 E. Broad St., 3rd Fl oor
AY 2 201
Prescribed : 5/--/2011, Rev. 12/13/12
(Required pursuant to R.C. 291Q.123)

'(Day Year
btomplete abortion Adverse reaction to RU-486 _ Patient hospita lized
6. Duration of event: _ _ _ _ Hours ____ Days
7. Remarks:
8." b. Physician' s signature

Legal Department
MEDICAL BOARD
APR 2 6 201
Prescribed: 5/--/ 2011, Rev. 12/13/12


Month Day
'"Year
ICtnn(J ar{v1+-h:, ,J S o~fh~ D~ ; o

Ct\t) uh VJ c-. k;/ tJ H- l/S-2-- 19

oZ~I Lf ~hv1.r"' /rv-{.
'
:J/2-s l\lt
5. Event(s} {Please check al l that apply):
- Adverse reaction to RU-486 _ Patient hospitalized MEDIC
APR 12 ; 016
- Patient received a transfusion _ 0evere bleeding
6. Duration of event: Hours 2--- Days
7. Remarks:
i) o ,1/'\C(f w-u-,( f <LJ '1--L
18. a. Name of physician who provided r

I
Date _ _ '-1,
~1_J1
--'--/;~
! (,,_ _ _ _ __
legal Department
Prescribed; 5/--/2011, Rev. 12/13/12


Mont h Day Ye ar
2. Name of medical practice or facility at which RU-486 was provided :
t d-i[)l5D 6 ~ 6 \vd
4. Date post RU-486 complication beg;~/,1h/J~
5. Event(s) {Please check all that apply): / /
~ mp lete abortion _ Adverse reaction to RU-486 _ Patient hospita lized
_ Patient received a transfusion _ Severe bleed ing

----------------------
6. Duration of event: - ~~:;.=....t:- Hours _ _ _ Days
7. Remarks:
///Jo, ~(;nA-
8. b. Physician' s signature ----1;r-/-1r-

)L}--#'~--.~-"',...~"'"""ece..~""""~" ------.. .~. .......AC-i......~:aJ..-ou....--
Date ------,, ~~ G-1-f-"E:,'3~ - - - - - - -
Lega l Department
MED1cAL Bo
Prescribed: 5/--/2011, Rev. 12/13/ 12
APR 11 201
(Required pursuant to R.C. 2919 .123}
1. Date RU-486 was provided: lb

Month Day Year
tfl{J ~ D
~complete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Oth er serious event (specify)

-----------------------
6. Duration of event: _ _ J~-- Hours ____ Days
Send completed forms to : State Medica l Board of Ohio
Lega l Department
EDlC
~PR 11 '2.\1\
Prescribed : 5/--/2~1, Rev. 12/13/12
Report of RU-486 Event MEmcALBoARD
(Required pursuant to R.C. 291Q.123) MAR 8 201

Month C>ay
\~
Year
JI./% f, \'-\6',(~ *~
~l~ 6t L-f~~tr
.,
5. Event(s) (Please check all that apply): -;,
\., .,
\.-., ~...... :-,,::1. -

~ p \ e t e abortion - Adverse reaction to RU-486 _ Patient hospitalized

.
6. Duration of event: ~~- Hours Days
7. Remarks: 11,t,( d_ m fc(!:) C('\0(\ \.) tabl.t. I uP) cl.-L t-o

rb" f-'~'~
8. a. Name of physician who provided RU-486 GO.."thui (\.l_ (~ <?'f'i\OJ\O ~
s: b. Physician's signature (l,.t~{Ss' ~/DO

legal Department
Prescribed: 5/--/2011, Rev. 12/13/12

:: , .. . ~ .
' ... ;..
. ;' ~:~~:- .: =
~.; ~:i. I

Month Day Year
2. Name of medic:al practice or facility at which RU-486 was provided:
fJ 0 h-ett~f Oh,1 VI/} vn

MEDICAL BO
~omplete abortion Adverse reaction to RU-486 Patient hospitaliz
- R 7 201
6. Duration of event: _ _ _ _ Hours / U Days
.,,,,-
8. a. N'ame of physician who providec!_ RU-4f 6
Legal Department
Prescribed : 5/--/2011, Rev. 12/ 13/ 12

....:,(;~:~':;> Report of RU-486 Event
\,Jf;~_J{)~ . (Required pursuant to R.C. 2919.123)
... .. ....

II D'f
Month Day Year
ffa~y'l(./ for~ud "'-~0 Ohio ~f/c>-t

cJ31<-f Mv1r/"' ft I
UVl C,)r, jf'\Ci, t-1' I off L/ r-2--1 9
tl /~ /I~
--6comp lete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

-
6. Duration of event: {J/ Hours Days
17. Remb~ ( -rur/-Ofrtv~ r? cJ

~ --
1
I
18. a. Name of physician who provided R ~ ------t;,"--";........o'--...:;;...---"'=--....;...,_

_~_ _ _ _ _ __
8. b. Physician's signature -z;,,~~---;,""--"'~-------------.p;.~~~i<-1-l~DuO-L-.-
.
1
Date ------'~-?l4-t---=-l/_,_d~'----------
Legal Department
30 E. Broad St., 3rd Floor Mf,DlCAL BOA.RD
DEC 091.0\
Prescribed: S/--/2011, Rev. 12/13/12

Month Year
2. Name of medical practice or facility at which RU-486_was provided:
~ro

/0 2-'!J UJ\~
5. Event(s} (Please check all that apply):
~ complete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _ _ Hours ____ Days
7. Rem arks: /fl l'Ofll(.)1-t -le_ rn,d. ; CA fict') a.kit ti d) 1i} I / o u) 1~

~-\-neo\ .
8.' b. Physician's signature

Legal Department
NOV 2 2015
Prescribed: 5/--/ 2011, Rev. 12/13/12
._ /I.I ~
~ / .

2. A-:~:I Month
practice or facility at which RU-486 was provided:

Year
!J,a::o ~ IJ,vJ. e..,1<..11. J~ L..{L{ I~
4. Date post RU-486 complication began: !Pj/P/~

, ,
- 6complete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

------------------------
6. Duration of event: _ . . . . ~ r;.....L-- Hours ____ Days
7. Remarks:
8. a. N ame of physician who provided
Legal Department
Columbus, OH 43215-6127 . E
CT 201~
Prescribed : 5/--/2011, Rev. 12/13/12
1. Date RU-486 was provided: of Month

; t:J
Da y
16
Year
2. NamK of medical practice or facility at which RU-486 was provided:
'Pt--e+e.~
1diOOo 8.,..a/~if" 6/vd... CJ.<2-ve\ J t/l(/~ V

, I .
~ mplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: - 2'~-- Hours _ _ _ Days
8. a. Name of physician who provid
Legal Department
MEDICALBO
Prescri bed : 5/ --/ 2011, Rev. 12/13/ 12
CT 15 201
.:-:"_'- '_;/;,~\ Report of RU-486 Event
: -,)fL~Jf./~ - (Req uired pursuant to R.C. 2919 .123)
. ... . - .

Month
11:
Day Year
P(a l'l f'\l j' t>,r t-1">+ ho A 1h (# ~d- Dh ; o

3. Address of medical practice or facility at which RU -486 was provided:
4. Date post RU-486 omplication began:

3 & 1(
5. Event(s) {Please check all that app ly):
U 3 201
~comp lete abortion Adverse reaction to RU-486 _ Patient hospitalized
Patient received a t ransfusion _ Severe bleeding
_ Other serious event {specify) - - - - - -- - - - -- -- - -- - -- - -
6. Duration of event: _ _ _ _ Hours / t Days n//:;c,!J ~ fr 1 ;0~ a _{,f I' /Nd .

7. Remarks:
P+- ~ rJ. rJ ~d t.,J /fl
18. a . Name of physician who provided RU-486

I
18. b. Physician's signature ~ ~
// -
~ ? MD /D 0
Date--------------------
Send comp leted fo rms to: State Medical Board of Ohio
Lega l Department
Prescribed: S// 2011, Rev. 12/13/ 12


Month Day Year
Pltt--1n(J ()ar(,;"}~kc:>JJ ~u fh ~JI-- Oh; V

,cal practfceor facility at which R0:::2IB6 was provided:

U / ;g I~
G
~ ncomplete abortion Adverse reaction to RU-486 _ Patient hospitalized

----------------------
6. Duration of event: _ _ _ _ Hours 30 Days ro//~v0 vi'
7. Remarks: t/ a-/f-r-~~1-dt ~ vJ, ~ ~ vf;Jg a ,.___-4--

p-+-. IA tvf,< ~
/V' / .J;. 0 /?/'OJ j-r;J ( I
h ~c/ cU'?L 0"'1 .:r/2-1 /1r- (/JI ~...vf- ;:;~J_
'
8. a. Name of physician who provided RU-486 dAeo'==' h~ ,,,,--

1
1
8. b. Physician's signature ~
,,,/7 l,
- 62 D0
_
1
Date ----'7;
+---r/g
. . i: : : =:-'=-1-J~
4~ C--------
Legal Department
Prescribed: S/--/2011, Rev. 12/13/12


lk ;S
Month Day Year
4. Date post RU-486 complication began: , /

1 /OJ/~
I I
5 . Event{s) (Please check all that apply):
_Lincomplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

-----------------------
6. Duration of event: ;) ?' Hours _ _ _ _ Days
7. Remarks:
8. a. Name of physician who pro~
8. b. Physician's signature ~A ,I =-;. ~ DO

Date----~_.__.~.......::__ _ _ _ _ _ _ _ _ _ _ __

Legal Department
IUL 2 0 201
Prescribed : 5/--/2011, Rev. 12/13/ 12
1. Date RU-486 was provided: JD

Day
16:
Month Year
-~
1:i..000
4. Date post RU-486 complication bega; ;(, /IS-

I I
~ omplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

-----------------------
6. Duration of event: --:l
~-- Hours ____ Days
7. Remarks:
8. a. Name of physician who provide

Legal Department
MEDICAL BO
JUL 2 0 201
Prescribed: 5/--/2011, Rev. 12/13/12

Month
I/
Day Ye ar
e of medical practice or facility at wh ich RU-486 was provided:
C,l-lvc(~
I I
complete abortion _ Adverse reaction to RU-486 _ Patient hospita lized
6. Duration of event: - - - '~= - a . - - Hours ____ Days
8. a. Name of physician who pro

Lega l Department
Co lumbus, OH 43215-6127 EDICAL BO
Prescribed : 5/--/2011, Rev. 12/13/12

JUL .2 0 201
> :, .1~/t/./;.;?#
. "~ . ,,, .,...,.?

Month Day Year
e of medical practice or facility at which RU-486 was provided:
t'J ooz:> sla.k-er 6 {v) \--c v-J!~ t.{ Lf l?.

4. Date post RU-486 complication began: ~
~P115
r , 7
5 . Event(s) (Please check all that apply):
_bcomplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized

----------------------
6. Duration of event: __ ;2___ Hours _ _ _ Days
7. Remarks:
8 . a. Mame of physician who provided RU-486
8. b. Physician's signature ~ DO
Date ,11i2
Send completeq forms to: State Medica l Board of Ohio

Legal Department
JUN 5 2015
Prescribed: 5/--/2011, Rev. 12/13/ 12
-, To be completed by the physician who provided RU-486

D3
Month
/~
Day Year
1Jte1r~
( -
5. Event(s) {Please check all that apply): '

-----------------------
6. Duration of event: --=~;...,4..--- Hours ____ Days
7. Remarks:
8. a. Name of physician who p r ~ : ~ 6 /,_ ' .:,G 0....
8. b. Physician's signature ~--~--'3___:S:.. . ;::,,.:Z:::S

, :::::----~------_,
~..u...r+/-LD.L.J..JO~-
)
Date - - - + r - ' ~ ~ ; . _ __ _ _ _ _ _ _ _ _ _ _ _ __

Legal Department
30 E. Broad St., 3rd Floor MEDICAL BO
APR 2 0 201
Prescri bed : 5/--/2011, Rev. 12/13/ 12


D2 /l)
Day
Month Year
~ 1,---,,'"t.e hlv\
5. Event(s) (Please check all that apply): 7 7


----------------------
6. Duration of event: 3 Hours ____ Days
7. Remarks:
J{~:r,A ~~J ~'1}.


Legal Department
APR 2 0 201
Prescribed: 5/--/2011, Rev. 12/13/12
1. Date RU-486 was provided: bl /~

Month Day Yea r
~ N...+--c-J-W\
4 . Date post RU-486 complication b; g; ;~ / /{""
5. Event(s} (Please check all that app(y} : l

~ mplete abortion _ Adverse reaction to RU-486 _ Patient hospita lized
6. Duration of event: --=;2

:;;::;::,,,,,.._ Hours _ _ _ Days
7. Remarks:
8. a. Name of physician who provide<;)J

~ -4~ /Jp_i,.J-: .,_.,.._
l..17 ,;:_
8. b. Physician' s signature ~~.__~::::::::,:=------5

==----- -- {!!J)t D0
Date &} fr1o ,I~

Legal Department
Co lumbus, OH 43215-6127 MEDICAL BOARD
MAR 2 201
Prescribed : 5/ --/ 2011, Rev. 12/13/ 12
... . . ....
1. Date RU-486 was provided: I j_ 11

Month Day Year
/J/tu,ned ~~lil.,O<>e/ f'~ -/n ~ I o h,o

~ "2::>1 '1 ,Avbvr 11 A,-v.e
{1111 CI n 11 a A ort 'I ; --)1 'i

i,;2_/30/1'/

-
6. Duration of event: fJ- Hours Days
17. Remarks:
I
I

Legal Department
MEDICAL BO
Columbus, OH 43215-6127 FEB 20\
Prescribed: S/-/2011, Rev. 12/13/12


0/ JI
Month Day Year
~.-L<k.rL/IA.
Adverse reaction to RU-486 _ Patient hospita lized
6. Duration of event: - - - '~"""-Jo---- Hours ____ Days
7. Remarks:
A-bo.-l-:ov-- w~\-dd.
8. a. Name of physician who provide

Legal Department
MEDICAL BOARD
FEB O201
Pre scribed : 5/ --/2011, Rev . 12/ 13/ 12
. - - -"i .::-
\. A ~I ; ' .'
,. , ""' " (Required pursuant to R.C. 2919.123)

-, ~ --""'
1. Date RU-486 was provided: \

Day Year
~f
4. Date post RU-486 complication began: \ \\C,

110
~complete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify} _ _ _ _ _ _ _ _ _ _ _ _ _.....1_ _ _ _ _ _ _ __
6. Duration of event: t\.) lV\. Hours ____ Days
7. Remarks:
Date _ _ _ _ _ P
. .:__~~-+A
I
.:. .:. 3ii+l1-..,j1.....-_ _ _ __
i

Legal Department
Columbus, OH 43215-6127 MEDICAL~ .J ..
FEB 20\
Prescribed : 5/--/2011, Rev. 12/13/12
I
.. State Medical Board of Ohio
Re~ort
I
of RU-486 1:vent
i
1 (Required pursuant to R.C. 2119.12~1)
T~ be completed by the physician who provided RU-486
!
1. Date RU-486 was provided: JO

Month i Day Year
2. Name of medical practice or f16ility at which RU-486 was providEid:
pLA'~~ ~b ~ ~-.-Jl)#oJ) oP ~ ,~'L, t> Hi o
3. Ad~ress of medical practice or ~acility at which F.IU-486 was provided:
2 53 :Su ~ c,,f6S ,.J) F /) b PJJ roM lfT3, o H Lf 4 t lf (p

! /
I
4. (?ate post RU-486 event began!

1 'V/, ~/u;,t{
I "
/ I
_V_ 11ncomplete abortion 1- --!i-:.
Adverse reaction to RU-486 _ Patient hospitalized
_ Patient received a transfusion

,-
I
1
Severe bleeding
_ Other serious event (specify) _ _!___________--+---------

! I
I
6. Duration of event: _<__/ __ ~ours _ _ _ Days

I ,,
7. Remarks:
8. a. Name of physician who provii ed RU-486 Tl NI o,H-,,f K-,I;'. ss, ,v1 f)
8. b. Physician's signature j-~ ~ .. TTAA ~ - ./D.O

'
Date _ _ _
, 2-- '"'L-
_ \+-'\__ _.\__
\+_ ,_:- - - - - - - - -
i
Send completed forms to: ,tate Medical Board of Ohio
:[gal De~artment
MEDICAL BOARD
3P E. Broad St., 3rd Floor
I
901umbus, OH 43215-6127 DEC 17 2014
Prescribed: 5/--/2011 I
! ,
"
:, , j ./
;:,
;
-- -;,.J-
~
1. Date RU-486 was provided: \\ /\ 't> /U\'f

Month Day Year
2. Name of medical practice or facility at which RU-486 was provided :
f rt\-\
. I
5. Event(s} (Please check all that app ly}:
~ncomp lete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Patient received a transfusion _ Severe bleed in g
6. Duration of event: tJ1A Hours _ _ _ Days
7. Remarks: fa l LQ,ct (n-tclJ ca\ tdo

'P\f\'l~ cO j .
8. a. Name of phys ician who provided RU-486

Lega l Department
Prescribed: 5/--/ 2011 , Rev. 12/13/12

1. Date RU-486 was provided: / ?J 12 ~

Month Day Year

~ omplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify) - - - - - - - - - -

-------------
6. Duration of event: c2 Hours ____ Days
8. a. Name of physician who provided w

RU-486;
/1//, ,\, J,.- -- ~ ~
8. b. Physician's signature -r
/ --,...
l'-r-,......;~-,.....---1.~
.- - - - - - - - - - - .~~~~D.L.VO--
Date -----+----.~-->-------------
Lega l Department
MEDICAL BOARD
Prescribe d: 5/ --/2011, Rev. 12/ 13/ 12 NOV 2 0 2014


/0
Month Day
If(
Year
2. Name of medical practice or facility at wh ich RU-486 was provided:
-A--c+~

(/)
..z-
C)
< a:?:
Adverse reaction to RU-486 _ Patient hospitalized -no
rn
~ mplete abortion
OJ o('")
-
~
=c>
-, ,':) ,
Patient received a transfusion _ Severe bleeding CD
c5 C)
C) >
;o
Cl)
C)
6. Duration of event: --=-~---.~- Hours ____ Days
7. Remarks:

Legal Department
Prescribed : 5/--/2011, Rev. 12/13/12

siate Medical Board of Ohio
RePort
I
of RU-4861:vent
I
I (Required pursuant to R.C. 2119.12~:)
I
Tp be completed by the physician who provided : RU-486
I ,
i

Month : Day Year
2. Name of medical practice or fibility at which RU-486 was providE;,d:
Pvfi-"N N'2; 1) p~-1'J.11# 0 .i) 0 F ~ ,~ I L - i~ In 0

I '
3. Address of medical practice or 1acility at which SU-486 was provi1:~ed:
:Z 5 3 Sb ~ c,,~ '--U I?' 4-0

! /
b ?J) ro/Lb 1-/73 / o H Lf 4 1 Lf (p
I
4. Date post RU-486 event began!

. q / 10 I t./-
J I
I
~ complete abortion \_ Adverse re~~ion to RU-486 :_ Patient hospitalized
_ Patient received a transfusion 1- I

Severe bleeding ME[ ICAL BOARD
I
I
I ! EP 2 2014
_ Other serious event (specify) - ~'- - - - - - - - - - -.........- - - - - - - -
!
.
I
I
-
I
6. Duration of event: _ _ _ _ ~ ours _ _ Y
~- Days
II ,,
7. Remarks: ft rece,ivecl med,ctt}on a.bor-tfon per- FbA approvecl protow{ it1--trav+e.nn.e.

debris on uJ+n:1.souncl a:f JY.4cuJ-R>llou>up visi-t wi+hovi-v1abl.L..p~r,aV10j Trut.-te-d
w,~ 2- w~x~ Mi.sofY1>5-P\ 01'*10Ld (;()mp l1a:fi0vt. Comf lei-e t:tboriion cnnB,<V\e_d
by v \km~ov\'1cl . I
l
8. a. Name of physician who provit ed RU-486 Timo+vi~ kre ;s., MD
8. b. Physician's signature I .--, l : l ~ 7 . _ ... c_ ~~ .D D.O
Date _ _ _<==t.l,,..\~7...::::_~4-~ \.\-.l...
\'..,\:+,!._ _ _ _ _ _ _ __
!
Send completed forms to: i tate Medical Board of Ohio
~egal Deijartment
I
901umbus, OH 43215-6127
Prescribed: 5/--/2011
I
I
sfate Medical Board of Ohio
Re~ort
I
of RU-486 1:vent i
l
1 (Required pursuant to R.C. 2119.12:,)
I
Tp be completed by the physician who provided : RU-486
I
Ii
1. Date RU-486 was provided: : 29
Month i Day Year
2. Name of medical practice or f16ility at which RU-486 was providHd:
f vf\'"N~ ~b ~lh1.{;,r-J n#oi> 0 r ~ ,~!\_ ~- ~ If, 0

I
3. Ad~ress of medical practice or 1acility at which BU-486 was provided:
2 s:; sn rLt> c,.f6-S ,-.u e- M

! /
-t f?J) ro M I-/T3 , o 1-1 .
I

01/1,/zo,1
_
V::Incomplete abortion II-Adverse reaction
"' to RU-486 _ Patient hospitalized
_ Patient received a transfusion 1I- Severe bleeding
ii'.
_ Other serious event (specify) ------------------+----------

! I
6. Duration of event: _ _ _ _ ~ ours __(_ _ Days

II ,,
7. Remarks: p+ unde..rwe1-t- Fb\A

t\.ffl'Oved prutow ( ~ -w,
:'ca-tlo Vl t:i..bo,-tton w,Tu ()
Pre.e nttnl<.,j -test- (t; wed~-~ la.-lfr, btoodwct1:: c.onfkrv,s 1r1wn,1pk-fe.. cd:::oMioYL I recd-ed
Wiil'\ h)\3.)prostol 800 my Iw f-+viou{ e-owi p\f ca:-tfo ri-
1
I
8. a. Name of physician who provit ed RU-486 II mofltt v1 k'..re .<;(, tv'l h

8. b. Physician's signature ! ~~~
-----------L------+--------. . .~~-;-
. ,v,.D. D. 0
i Date _ _ _ c -=r
":t-~\,......--+-
1_\LI--
~ : _ _ _ _ _-_ __
II
' .
I
Send completed forms to: iate Medical Board of Ohio
I gal De~artment MEDICAL BOARD
3P E. Broad St. , 3rd Floor
. I
q o1umbus, OH 43215-6127 SEP 2 6 2014
I
Prescribed: 5/--/2011 Ii ..
I'
l
I
Re~ort
lj of RU-486 l:vent
'
I
! (Required pursuant to R.C. 2119.12~)

I
Tr be completed by the physician who provided . RU-486

I
I
1. Date RU-486 was provided: Pn iiil \ ,-\- 2-D

--L-l~~~---4-=-=-----.;::..=:.~.L..----
'20 l ~
Monlh Day Year
2. Name of medical practice or fi cility at which RU-486 was providE d:

Pla.vw,d Par-e1-Htl~ of 6re.tt-+e.r 0Vtio

I .
25350 RoG\L~\k f ~ ~ford ~l~VttS, OH L 4-l<f~
i
!
4. Date post RU-486 event began:
. I
I
I
~ ncomplete abortion 1- Adverse reaction to RU-~86 _ Patient hospitalized
_ Patient received a transfusion II- Severe bleeding
I
I
_ Other serious event (specify) - ~i- - - - - - - - - - - - i - - - - - - - - - -
1
I
6. Duration of event: __
L:.._( __ ~ ours _ _ _ Days
!
7. Remarks: p.;- undexwe..v\-t I rDA ttpprov-ed pro-tow( -Fo, m,e.dcc.a..-flor'\ ttkPA-tC>r\

w,fu C-or1-tin\..),VVJ v llk)Le pie.'jMV1Ly ~+ -futlowup . t:>t el cte.d <;;.ua::f:.-tt-l
Cil5f l ncti 0111 WV1 ,c.,h Wet S rf<w
! -
(vv\.Q_6 l)) ( ~ out CO VV\ f UL-ti O V\ - 1
\
II
8. a. Name of physician who provided RU-486 k.c e.ss

rtmOfuL\ J ~1)
8. b. Physician's signature ~ Ir ~ ~ a -:o. D.O

I - Date ,q \eo l. l 4'
I
I
Send completed forms to: 5itate Medical Board of Ohio

Lbgal Department
3b E. Broad St., 3rd Floor MEDICAL BOARD
I
9 01umbus, OH 43215-6127
SEP 2 6 201
Prescribed: 5//2011 I
1.
I

Month Day Year
f'ir--e. kr ""-
1d\ DVD 5~/za- ,6{vl, \wcl~ 44 l~

m/i.J.//(
{ /
'
~omplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: t/
(
Hours Days
7. Remarks:

Legal Department
MEDICAL BOARD
SEP 2 2 2014
Prescribed: 5/ --/2011, Rev. 12/ 13/ 12
..
:- :->~: ._

Day Year
fVOH
~{~\r;~;{di~nctis~1ity at which RU-486 was provided:
C0\l{M~l,U O L\-~Z\~ I
~ \).. 1-A)'
5. Event(s} (Please check all that app ly}:
Vincomplete abortion Adverse reaction to RU-486 _ Patient hospitalized

I
I
_ Other serious event (specify) - - - - - - - - - - - - - - - - - - - - -
6. Duration of event: ~ Hours _ _ _ Days

7. Remarks:

Legal Department
30 E. Broad St., 3rd Floor ICALBOARD
SEP 19 2014
Prescribed : 5/--/2011, Rev. 12/13/12

1. Date RU-486 was provided: ()7 03

Month Day
~ mplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _ _ Hours - ......-

{ - Days
7. Remarks:

Legal Department
Prescribed : 5/ --/2011, Rev. 12/13/12

1. Date RU-486 was provided: Ob

Month Day
~ty~
j L{L{ I D
5. Event(s) (Please check all tha
Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _ _ Hours _ _( __ Days
7. Remarks:
Ahoi--..\..;""" l=~-eiA vO': '-J!_Qt

8. b. Physician's signature~ ..,......,..,,... q_""7"----------'1"-4,,,1. . .

~-+-+--._ . . . ,ff-f,~,__-
Date _________..........,_ _ _ _ _ _ _ _ _ _ _ __

Legal Department
MEDICAL BOARD
JUL .1.4 2014
Prescribed : 5/ --/2011, Rev. 12/13/12
Re~ort of RU-486 :vent
Ii (Required pursuant to R.C. 2119.12~l)
Tr be completed by the physician who provided RU-488
1. Date RU-486 was provided: I o '1 r1-

I
I
Month Day Year
2. Name of medical practice or f16ility at which RU-486 was providEd:

pvA.'1 r-l ~ b Pth'lk,,U1# o J) o ,::: (;,~ 1 - P H, o
I
3. Ad~ress of medical practice or ;acility at which F.lU-486 was proviljed:
:Z 5 3 Sb ;lb c,,f6-S ,-J) e- ~ ~ f?J) fv (Lb ifT3 1 o H '-( 4 1 Lf (p

I '
I
4. Date post RU-486 event began i

. I
l
I
l0 - 3, - 2-,0\ '3,
!

!
.
'\11>-_
_ Incomplete abortion i- Adverse reaction to RU-486 :- Patient hospitalized
j Other serious event (specify) I

fit\, tA;--U IV\ r.D I C1'l-n or-I A- f!,o IL n o --J
II
I
Jl5_
6. Duration of event: _ L_ \_ _ ~ours _ _ Days
I "
7. Remarks:
8. a. Name of physician who provided RU-486 J) ~ 1) lr..h D l1-Jt,,t..MGAJN.S

,s signature
8. b. Ph ys1c1an ~~-,..~ , ~ V-v~"" ( ~~~s . AAt:> M.D. / D. o
11
Date \O ~ \ \~ .
\ { ~ ' o-.e 01 .('-<- c_~ o../'"'""
I ' \ ...
I
Send completed forms to: State Medical Board of Ohio ~~!-\-. \
~ gal DeP,artment MEDJCALBOA
3 10 E. Broad St., 3 rd Floor
I OCT 2 6 2013
go1umbus, OH 43215-6127
J
I
II ,,
1
!
~59

Report of RU-486 Even
.........

(3
Month Day Year
PlavlV'lJ Par~~aJ) So~~~ c?4, ~'i{t' D"

~~ I \.f ,.A'\.A,vrn Aw, C I~ v,~l"'\tJt- , c>tr y~~ ,1

I

6 / u /,~
L incomplete abortion
6. Duration of event: Hours Days mo,.., r-h~ h, ,., 3w t-0.

7. Remarks: +- ~ rf)On1 ~~ ovtr -PM v - ' ~ 8\1'"\U
0 fl crr
b (w;( (V\
~ J)4_ ~ P o,d J~ n o+ t #C?t-:~ .

. r
V',.t
1
8. b. Physician's signature _ _ __.....,..
~- - - - - - - - - - - - _ _ , .((92
.....i..-/-/-1.0.i.O~-
Date ---'-/_l,_,/__. 4-+-

. . j-~- - - - - - - - - -
Legal Department
Prescribed: S/--/2011, Rev. 12/13/12

O\CA BOAR
State Medical Board of 0
15 2013
Report of RU-486 Even CT
.........

[~
Month Day Year
Pr~v)~ P~~k,~ ~.A,~~ oh-? ~cr1'~

;2_ 'b {lf ~bv1r/' faM , LA /'\CAV,., vt:k) I

otf- ~ [ ")_ 17
_,
G/~/G
5. Event(s} {Please check al l that app ly):
_ Incomp lete abortion
- Patient received a transfusion .-0evere bleeding
6. Duration of event: ~ Hours Days
17. Remarks: (*, hoJ J)'d- (_ o-+ -f-o d r op t' n

+th ~ ct ~ of h( o 'J d
Ir\ v. f-t r U<:l
18. a. Name of physician who provided RU-486 60 1,

I
,8. b. Physician' s signature v ~ @ .too
Date ----L./_O
--'-/_q.J. . ./J.-!.13
. . ._ _ _ _ _ _ _ _
Send completed forms to: State Medical Board of Oh io
Legal Department
Prescribed: S/-/2011 , Rev. 12/13/12

IOCT l ~\H3
.... . ....

Month Day Year
2. Name of medical practice or facility at which RU -486 was provided:
(}Jt;nNJ ()ar~a/ ~c9v<,fi,~ o}+,'.:;

-
cJ-b I~ ~ /' ,')

~' G 0&tV1r1aJ-; (
CJ-ff 4 s21q
&, / 1i J13
_Lincomplete abortion

-
_ Other serious event {specify)
6. Duration of event: Hours /0 Days
I7. Remarks :
p}. he. J n D.-i - v c' ah>~ 6~ c
cJ<) '1( f){ ~ 1( )(( ~

'
18. a. Name of physician who provided RU-486 ___ . ;~: =-~-=:...::.....:.._.;..k~L..:....-'_______
1
8. b. Physician's signature ----,!~:,.-'-~~- - - - - - - - - - - - ,~u.w....J,a---1-/-L.01.,..10..1-._
Date _ _-...L-
J o__,,r1 - t;.;. . ,/:__;L~
S --------
Legal Department
Prescribed; S/ --/ 2011 , Rev. 12/13/12

Report of R-U -486 Event
1. Date RU-486 was provided: y 10 ao/3

Month Day Year
"

q {p Ii
~mplete abortion Adverse reaction to RU-486 _ Patient hospitalized
Patient received a transfusion _ Severe bleed_ing .
6. Duration of event: _ _/..... __ Hours ____ Days
7. Remarks:
8. a. Name of physician who pro 1
8. b. Physician's signature ~J_Yf__j.~---~~/s..:;::::==:=t::;:~W'L./.'..D..0--
Legal Department
Prescribed: 5/--/2011, Rev. 12/13/12

~';f;t6'!T
v~~rr,~. (,.'
s{ate Medical Board of Ohio
i
(!fi;.'.;_;;;;,Jf/ RePiort of RU-486 vent
\~(i I (Required pursuant to R,C, 2119.12 )
Tpbe completed by the physician who provided : RU-486
I
i
Month Day Year
2. Name of medical practice or tjbility at which RU-486 was provid ' d:
f vf\"N i'1 lTb ~fr#~il# o J oF {;,~ I \ - , If, o
3. Address of medical practice or iacility at which BU-486 was provi : ed:

I
2 53 Sb ~ (,,ft.>-S I._LJ F'" 4,-0
! /
I

. I
!
l
/ I ~ ~~ .
_\_/ lnnccomplete
I abortion 1- Adverse reaction to RU-486 Patient hospitalized
_ Patient received a transfusion 1-

I
Severe bleeding
_ Other serious event (specify) -~------------+---------

'1
'.
\
I
6. Duration of event: __ 1...___ ~ ours Co Days

I "
7. Remarks:
8. a. Name of physician who
I
Send completed forms to: State Medical Boa d of Ohio
MEDICAL BOARD
~ gal DeP.artment
sbI E. Broad St., 3rd Floor SEP O9 2013
901umbus, OH 43215-6127
! I

!JZ
Month
[)('
Day
/3
Year
2. Nam;\ of medical practice or facility at which RU-486 was provided:
f\--r.+-er~
l ~oz:rt> jkf<er 6/vd, CJ-r-v-d ~ DH- l/t(l~o

jo?&,/13
/ i 'ncomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: Hours I Days
7. Remarks:
/l&rl- ttn,-t;J-c?d jt,v-J-:r~ ~ -t/rJ.t,,/!J, .-o -\., ~ tp~p!;u:k~.
8. a. Nam~ .of ph~sician who provide~

8. b. Phys1c1an's signature ~ ~
w-..&..of ()"e: n
Date ""i,.;'--,~I:.)
I I
Legal Department
AUG 12 2 13
Prescribed : 5/--/2011, Rev. 12/13/12
::,tate Medical Board of .O 10
l M DIGA OAR
Reoort of RU-486 . ven ..
'T (Required pursuant to R.C. 2119.12. )
1
JUL Z 2 2013
!
I
Tr be completed by the physician who provided , RU-486
i
I
1. Date RU-486 was provided: (3

Month : Day Year
2. Name of medical practice or fibility at which RU-486 was provid d:
PI.Ah'1 N~b pfht'U;--1'! .it# 0 J) 0 p ~ ,~ 1 . . - If, 0
3. Address of medical practice or ~acility at which SU-486 was provi '. ed:
I
2 s:; s-n ~ c,,~ ,Jj e- ~ , '7 P1) ro!LD f/T:3, o H:
I
4. Date post RU-486 event begarn
.
i
! 11,'v(,3
_
V:Incomplete abortion 1I- ,
Adverse reaction to RU-486 Patient hospitalized
I
Patient received a transfusion \- Severe bleeding
_ Other serious event (specify) _----;.!------------+---------

\
6. Duration of event: _ ___.0__ ~ ours _ _3_ Days

I "
7. Remarks:
8. a. Name of physician who ru.cutie1ett--R1~
I
Send completed forms to: ,late Medical Board of Ohio
Legal DeRartment
sb
. I
E. Bro~d St., 3rd Floor
901umbus, OH 43215-6127
I
I
1
l
i

Re~ort of RU-486 . vent
I
1 (Required pursuant to R.C. 2119.12 )
!
I
Tp be completed by the physician who provided RU-486
Ii
Month Day Year
2. Name of medical practice or t1bility at which RU-486 was provid . d:

Pt.Ah~~~ P~~il#oJ) op ~ ,~ - {l.., 14,o
I '
3. Address of medical practice or facility at which BU-486 was provi ed:

, I .
2 5 3 Sb ~ C,{6-S ,-J) -e- M
! /
.t f?J) fv (Lb ifT3 I O H
I
4. Date post RU-486 event begani

. I /
l.f Ip 1 I i-o1 ~
I
_ Incomplete abortion i- Adverse reaction to RU-486 Patient hospitalized
/ other serious event (specify) _ _ !_trvve

__?YL
__ ~
~_l_ '--_ _ ___1'_ P_ ~- - - - - - - - - -
l
I
6. Duration of event: _ _ _ _ ~ ours _ _ _ Days

II ,,
7. Remarks:
8. a. Name of physician who provi

1
8. b. Physician's signature !
!
Send completed forms to: , late Medical Board o Ohio
~ gal DeP,artment
MEDICAL BOARD
3b E. Broad St., 3rd Floor
I
golumbus, OH 43215-6127 JUL l 2013
Prescribed: 5//201 1 I
j.
!
RePort
I
of RU-486 1:vent
,
i '
j (Required pursuant to R.C. 2119.12: )
I
!
I
1. Date RU-486 was provided: I tf Lf

1
------------------
Month : Day Year
2. Name of medical practice or f16ility at which RU-486 was provid0d:

PLAh.J ~ ~ ~ ~,-J it# 0 i) 0 f= ~ I {L-G1't,&{L- i~ If, 0
3. Ad~ress of medical practice or ~acility at which F.lU-486 was provided:

:1 s 3 Sb ~ c,,fl>-S ,JJ e- M 1 I
-t ?J) roM lf7-:s, o H. Lf 4 , Lf '-
'P

. lf/ IV ' ~ I
_
/ I , -~~ .
_/ _ 'l"n""c,omplete abortion 1- Adverse reaction to RU-486 '.- Patient hospitalized
_ Patient received a transfusion I-

I
I
Severe bleeding
_ Other serious event (specify) -----;.'- - - - - - - - - - - . . . . . . - - - - - - - - -

!
I
6. Duration of event: LI ~ ours _ JzJ

_ _ Days
I ,,
7. Remarks:
8. a. Name of physician who p r o * ~ ~ 6 J) rt,, ...!)}n/1.E.

8. b. Physician's signature Lf(J ,~'\._ , I - M.D. / D.O
~I Date - 14-:--f1//
" I II
~
I
gal Deijartment
3, E. Broad St., 3rd Floor ' ~-~EDICAL BOARD
'
J
I
r lumbus, OH 43215-6127
i i JUL 1 2013
'I ,
Prescribed: 5/--/2011 (
I .,_
1 , ---- -
'

Re~ort of RU-486 .: vent
I ,
l (Required pursuant to R.C. 2119.12 .)

I
I
Ti be completed by the physician who provided RU-486
1. Date RU-486 was provided: z_..o I

Month '. Day Year
2. Name of medical practice or fi6mty at which RU-486 was provid . d:
pvf'.'1~ ~b P~""11#0J oF ~ ,~ ' L . - Hl o

I
3. Ad~ress of medical practice or ;acility at which BU-486 was provi . ed:
2 5 3 :,b (l.(> (,,f6-S ,J) e- ;t..J) b f?J) fv /Lb 1-/73 1 o H Lf 4 t Lf (p

i /
I

. I
tr/ I <{; I ' 3- l!

v<:::.. I .,..
i-
I-
_ Incomplete abortion Adverse reaction to RU-486 Patient hospitalized
_ Patient received a transfusion Severe bleeding
I
_ Other serious event (specify) _ _\_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
II
6. Duration of event: ____JZ>

_ ~ ours 1- Days
II ,,
7. Remarks:
8. a. Name of physician who pr
8. b. Physician's signature .D./D.O
I
~ gal Dei:iartment BOARD
3b E. Broad St., 3rd Floor
I
9 01umbus, OH 43215-6127
JUL 1 2013
Prescribed: 5//2011 II
1
!
!
siate Medical Board of Ohio MEDICAL BOARD

Re~ort of RU-4861:: vent JUL 1 2013
I (Required pursuant to R.C. 2119.12~;)
Tr
I
be completed by the physiclen who provided RU-48G
1. Date RU-486 was provided: I-( q

Month i Day Year
2. Name of medical practice or f16ility at which RU-486 was provid1'd:
PLAh~~ ~b ~~~;,#o J oF ~ ,~ ' 1 . . . - PH, o

I '
3. Ad~ress of medical practice or 1acility at which 13U-486 was provided:
:z 5 3 s-u ~ (,,f!-S f-.LJ e- /) b ?J) re> M ifT3 l O H '-( 4 I Lf (p

I '
4. Date post RU-486 event began l
. I
l
I
!
5. Ev nt(s) (Please check all that apply):

I " ~-
_ Incomplete abortion 1- Adverse reaction to RU-486 :- Patient hospitalized
I
_ Patient received a transfusion I Severe bleeding
i-
Other serious event (specify) - - -l - - - - - - - - - - - - - . . . . . . . - - - - - - - - -
l'
_
1
I
6. Duration of event: __ L_,_ ~ ours _ _

II ,,
-Jo
_ Days
7. Remarks:
8. a. Name of physician who provif ed );1U-489'J_ J) /l- S 'rllA'rrl
8. b. Physician's signature I / ~ ~ 1 , / ""' M.D. I D.O

\
I
1
lfi;l-vJ It t fl /3 I
l
Send completed forms to: 11ate Medical Board of Ohio
~egal Deijartment
I
golumbus, OH 43215-6127
IMEDICAL BOARD
I !' 1 1 ?013
Ii
Prescribed: 5//2011
,. ,, _1
Re~ort of RU-486 : vent
l
i (Required pursuant to R.C. 2119.12~)
!I .
Tp be completed by the physician who provided '. RU-486
II
1. Date RU-486 was provided: 0(,:, (<f
Month I Day
Year
2. Name of medical practice or f~bility at which RU-486 was providE d:
PvA.'1~~1) P~,'1-~oJ o~ ~ ,~1-, ~>14,o

I
l '
3. Address of medical practice or facility at which ~U-486 was provided:

I .
, .A - I
2 5 3 Sb fUJ (,//1->-S ,J) e- M
! /
b f?J) fv (Lb ifT3 I O ff '-f4tl((p

. I
1
I
!

~ I ~ .~~ .
_ Incomplete abortion 1- Adverse reaction to RU-486 _ Patient hospitalized
I
1-
1 :
_ Other serious event (specify) -~'------------1----------

\
6. Duration of event: lf ~ ours __$3

__ Days
I
I '
7. Remarks:
8. a. Name of physician who pro~ e91!~86/ J) rt, ~h+-

f.Dvi/v.,r , ,
Vj\ I
l
1
D
" fJl!L /3 ;
I/ / -
M.D. I D.O
Send completed forms to: l tate Medical Board of Ohio

1
]egal DeRartment MEDICAL BOARD-
30 E. Bro~d St. , 3rd Floor
I
9 01umbus, OH 43215-6127 JUL t7 2013
,.
j ,,
state Medical Board of o io
RePort
I
of RU-486 vent
I
I (Required pursuant to R.C. 2119.12 .)
Trbe completed by the physician who provided , RU-486
i
1. Date RU-486 was provided: j
iI Month ! Day Year

I
2. Name of medical practice or f~6ility at which RU-486 was provid d:
PLAh'1 N~ p~,.J~ 0 i) 0 F (s;,~ 1 - - - H, 0
I <
3. Address of medical practice or ~acility at which F3U-486 was provi ed:

I
2 3 s s-n ~ c,,1&-S ,'1) e- M
! /
-t f?1J rv M 1-/13 , o If Lf 4 , Lf <p

. I~
l /I v/_
1JJ
I
_ Incomplete abortion i- Patient hospitalized
I-
_ Patient received a transfusion Severe bleeding
/ Other serious event (specify) ___.;.J..;..; =\;.;...;11t

t'1~;.....::;;..:...i....;.~~~~:;;.......i....;.....;..-+-___..~~i...::~~....;w il bi on
.:...:...i...---i..;;:;.___...-=--- s
I
I
6. Duration of event: - -~..__- ~ ours _ _I _

Lt-_ Days
I
I "
7. Remarks:
8. a. Name of physician who provi1ed
8. b. Physician's signature !
I
gal DeP,artment EDICAL OAR
I JUL i 2 2013
901umbus, OH 43215-6127
1
I
s{ate Medical Board of Ohio
RePort
I
of RU-486 . vent
I ,
j (Required pursuant to R.C. 2119.12 )
I
Tp be completed by the physician who provided ' RU-486
II
1. Date RU-486 was provided: Is
Month , Day Year
2. Name of medical practice or t~bility at which RU-486 was provid d:
PvA-NN ~b ~~"1-~oi) o ,::: ~, ~~ 1-1, o
3. Address of medical practice or facility at which BU-486 was provi ed:
:7 5' 3 Su ,A-
YUJ c,,f/->-S ,v e- I
M b PJ) fv /Lb lfT3 1 o rl '-f 4 , Lf (p
! /
4. Date post RU-486 event beganl
! 2 /u f 13
5. E";Pt(s) (Please check all that t pply): , ..... .
- ~- lnr.cnomplete abortion l- Adverse reaction to RU-486 Patient hospitalized
,-
I
!
_ Other serious event (specify) -~'- -----------+---------
!I
6. Duration of event: Lt ~ours Days

II ,,
7. Remarks:
8. a. Name of physician who p
Send completed forms to: ~tate edical Board of Ohio

gal DeP,artment
310 E. Bro;d St., 3rd Floor MEDICAL BOARD
I
golumbus, OH 43215-6127 JUL t'7 2013
Il
i1
!
To t:>e completed by the physician who provided RU-486

Month Day Year
j) 5 [. J 6(/2.te( WJ~ ~ 0/lt() 3L;3

4. Date post RU-486 event began : ; ;
7-4gA
5. Event(s) (Please check all that apply) :
~ m plete abortion Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious event (specify)" - -- -- -- -- - - -- -- - -- - -- --
6. Duration of event: _ __ _ Hours _ _ _ _ Days
7. Remarks: /'JrJ it.tt!l "J :r

t. {-( e ..{ I .. tie{,, ",cf lH """ (! ON (',"1' l.e h""
ff) / II/) ( fv/tf 4t (I[ &f.A/z ~
Send completed forms to : State Medical Board of Ohio

Legal Department
JUL 9 - 2.0\3
....
Prescribed: 5/--/20 11

Jc/13
Month Day Year
2.
j Ji~S- tfltl-1~ ~r:q (/Jfs. 1 ~II-to //J Lt 3

u/1 /,~
5. Event(s} (Please check all that apply}:
_)in comp lete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _/ _ Hours _ _ _ Days
7. Remarks: ll dn-u.
l
Date _ _ _.&
;:.. . /J,
:. .:.-=:t.,.!ft-L-_--====--
. :. -= = ==-~-
Legal Department JUL 9 - 2013
Prescribed : 5/--/2011, Rev. 12/13/12


Month Day Year
l~oz,z> sk~tr Jjf LC/. Ct{_~ DH ({Cf f~D

I/; If /17J
I I
L incomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: Hours L Days
7. Remarks:
8. a. Name of physician who provided ~
8. b. Physician's signature ~ 8 100

'-...3 (
Date Lf
J
, '2 ~ 5
Legal Department
EDICALBOAR
APR 201
Prescribed : 5/--/2011, Rev. 12/ 13/ 12
State Medical Boa.rd of Ohio

07 d o 13
Month Day Year
2. Namerff medical practice or facility at which RU-486 was provided:
r1r---<.+~ rVV'.
ODD J.
~ omplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _ _ Hours __/_ _ Days
7. Remarks:
fihw-h~ t~kk) sw-tJXZf


Legal Department
Columbus, OH 43215-6127 AUG J J .lfill
Prescribed : 5/--/ 2011, Rev. 12/ 13/ 12

i
I

Re~ort of RU-486 .; vent
I .
j (Required pursuant to R.C. 2119.12 .)
I
Tr be completed by the physician who provided , RU-486
I
i
i
1. Date RU-486 was provided: (--:f-

Month Day Year
2. Name of medical practice or fibility at which RU-486 was provid d:
PLAh'1 N~b pthllA?'N 11# 0 i> 0 F ~ , {L8t,b""')'l.-- If, 0
3. Address of medical practice or facility at which ~U-486 was provi ed:

. I :
2 5 3 Sb ~ c,,ft.>S '" ET /)
I '
b f?J) ro /Lb 1/73, oH Lf 4 t 4 (p
4. Date post RU-486 event beganl

. I
!
:
/ I ~ ~- .
_/ _,1-ncomplete abortion j_ Adverse re~~tion to RU-486 Patient hospitalized
II
Patient received a transfusion I Severe bleeding
i-
iI
_ Other serious event (specify) -~'- -----------+----------
6. Duration of event: __L_J _ ~ ours - -~- - Days

II ,,
7. Remarks:
8. a. Name of physician who provi~ed

i
8. b. Physician's signature ----
1 ~ - - + - - - - - - - - - - - : 1 - - + - -.......... . . . . _ ~ - - -
I
~gal DeRartment
3P E.Bro~d St., 3rd Floor
I
901umbus, OH 43215-6127
Prescribed: 5/.-/2011 I
!
'
Re~ort
I
of RU-486 vent
1 (Required pursuant to R.C. 2119.12 )
I
!
1. Date RU-486 was provided: :?013
Month Year
2. Name of medical practice or f1bility at which RU-486 was provid
PtAh.J ~ ~ Q~ n#o J o P: ~ ~-yt.,
3. Address of medical practice or 1iacility at which RU-486 was provi
:1 5 3 5 b fLJ; (,,f&-S sV F"

f tto
! /
b pt) fv (l1J ffT3 I O ,.,

. I
: ~ --- IL.f---/ 2:>
/ I .
_V
_llnncciomplete abortion 1
_ Adverse reaction to RU-486 Patient hospitalized
_
Patient received a transfusion
,-
I
1
Other serious event (specify) _ _!____________________

Severe bleeding
6. Duration of event: __<-_ , _ +ours _ _(;!_ Days

I
7. Remarks:

l
I
I
Send completed forms to: 5itate Medical Board of Ohio

Lr gal Department
3P E. Broad St. , 3rd Floor
I
qo1umbus, OH 43215-6127
i
I'
slate Medical Board of Ohio
RePort
I
of RU-486 . vent
I
1 (Required pursuant to R.C. 2119.12 .)
!
I
l
I
1. Date RU-486 was provided: ~Of 3

Month Day Year
2. Name of medical practice or fibility at which RU-486 was provid ' d:
PLA-\--1'[ ~ ~ P:'h'U:r-"1' ~ 0 i> 0 F ~ I ~1..- H, 0
l I
3. Address of medical practice or 1acility at which F.lU-486 was provi \ ed:
2 53 Su ~ (,,fbS 1-JJ ET ~ b ?JJ ro/Lb 1/73, 0 H Lf 4 I Lf (p

! /
I
4. Date post RU-486 event begarn
Il Z - d- ,)._. -, 3
L
_ - Incomplete abortion
I
1-
~ ~~
.
Patient hospitalized
_ Patient received a transfusion I- I

Severe bleeding
--------------+----------
I.
_ Other serious event (specify) I
\
I
6. Duration of event:
~, I
_ _ _ _ ~ ours
&
__?_ _ Days
I C
7. Remarks:
8. a. Name of physician who provi~ed

I
8. b. Physician's signature --+i.........,;~.--------------.--++---+.......----'t-- .D. / D.O
l
~ gal DeP,artment
3P E. Bro;d St., 3rd Floor
. I
qolumbus, OH 43215-6127
i
!'
I
State Med;cal Board of Oh;o

I
Re~ort of RU-486 vent
I

! '
I
Month Day Year
2. Name of medical practice or fi6ility at which RU-486 was provid
l 14-i..J rJ ,, D f ~..J ~o f> ur Ct~ n.K u--yc
3. Address of medical practice or ~acility at which RU-486 was provi

' 'J 315') /l,O<.JL-.S \I'~ C tl, ~-y:o,'U) Ih~ 0 \t- <.fl.{ I'--(
! '
l
4. Date post RU-486 event begam

. I
I
!
~ I .
_ Incomplete abortion i- Adverse reaction to RU-486 Patient hospitalized
I
I
_ Patient received a transfusion 1- Severe bleeding
_ Other serious event (specify) -----.1--------------...---------

6. Duration of event: ___%
_ ~ours _ _ _ Days
7. Remarks:

I
1
8. b. Physician's signature - - r -~ ---t~ ' T ' - - - - - - - - - i -"IH-- -+-- -~1.lf,l.;V
Send completed forms to: s'tate Medical Board of Ohio

Uegal
1 Department
3bE. Broad St., 3rd Floor
I
1. Date RU-486 was provided: 3 2-ol'L

Month Day Year
2. Name of medical practice or facility at wh.ich RU-486 was provided:

P\Ahned Pa..revrthc.-c.<l o.f- Grea:-kr . DV\\O

2, 5 :> $ 0 f2._o v K--~ r-cte_, \2-c(
W forvt \-t\-s I oH Y41lf lo
4. (?ate post RU-486 event began:
t } \ 4 /2,,0 I ?_
~complete abortion - Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious e~ent (specify)
.
6. Duration of event: Hours l Days
:
7. Remarks:
8. a. Name of physician who provid

Legal Department
30 E. Broad St., 3rct Floor MEDIC L O RD
Columbus, OH 43215-6127 2013

Month Day Year
P\o\ \ 1 ~ PG\ r~ooJ of Gre.tt-k< 0' \ o

Z.S '~ SO ~OG~\"ck (2...d I &d--R>~ +tt-s1 o\-\ 4-Y I Lf"'
1 / 1s I 2-e> I '2-
/incomplete abo~ion - Adverse reaction to RU-486 _ Patient hospitalized
- Patient received a transfusion ._ _ Severe bleeding
J
_ Other serious e'-:ent (specify)
I ,,,.
6. Duration of event: Hours ( j. Days
7. Remarks:
8. a. Name of physician who pr~ ......."'~ . . .

Legal Department
30 E. Broad St., 3rct Floor
MEDI ~LB ARD
Columbus, OH 43215-6127 JA 2 2 f
Prescribed: 5//2011
I

I ,
Re~ort of RU-486 :. vent

I (Required pursuant to R.C. 2119.12 )
TIr be completed by the physician who provided RU-486
I
I
1. Date RU-486 was provided: I

I
I
Month Day Year
2. Name of medical practice or ~~ity at which RU-486 was provid d:

P \'-V \ ~ c\ Pa..ren~ cf G<'etL-\-e.r CW\. ,Q
3. Address of medical practice or 1acility at. which RU-486 was prov,i ed:
?.- s ~ So l(:.oc/c..Sid,.Q_ /2.J r , !'.?led .fun:/ -1-t'i'"s I o H l/- / l[- (o
4. Date post RU-486 event began1
. I
10/ '2- . /z__ !
5. Event(s) (Please check all that apply):.
/incomplete abor'tfon I_ Adverse reaction to RU-486 Patient hospitalized
_ Other serious event (specify) -~--------------+----------
6. Duration of event: _ _ _ _ rours ___/__ Days
7. Remarks:
8. a. Name of physician who provi 1
8. b. Physician's signatur
I
Send completed forms to: State edical Board of Ohio
+gal Department
sp E. Broad St., 3rt1 Floor EDI AL GARD
1 olumbus, OH 43215-6127 4 2013
Prescribed: 5//2011
I
l
I

I . .
ReP,ort of RU-486 : vent
I (Required pursuant to R.C. 2119.12 ; )
I
Tr be.completed by the physician who provided : RU-486
. .
i
!
1. Date RU-486 was provided: JP

Month . Day Year
2. Name of medical practice or f1bility at which RU-486 was provid d:

f tAhJ rJ t;;J:, f~"f?r\1 ~ o !) o,=== 4> ~'~ D 171 .o
3. Address of medical practice or 1acility at which RU-486 was provi ed:

A :J J 5'J {lA) cAL-.S LlJ f: 1 ft.,{)
.bP1)fi) ,ti) ~ 0 ,+- I Lf Lf I t.{. ~ . .

. I
II-</ --r ~ I I

I
_ Incomplete abortion I- Adverse reaction to RU-486 Patient hospitalized
I
Patient received a transfusion \ ~evere bleeding
_ Other serious event (specify) -----;.1-----------.....---------

1
6. Duration of event: _ _ _ _ ~ours lf Days

I
7. Remarks:
8. a. Name of physician who providf

l
8. b. Physician's signature - ~'--r-1--+----1--__,,,~;...._+-,-__,,..--+-,~+------ M. D. / D. 0
Send completed forms to: S~tate Medical Board ~f

gal Department
3 E. Broad St., 3rd Floor M
Columbus, OH 43215-6127 JAN 2013
Prescribed: 5//2011
l
!
sfate Medical Board of Ohio

I ~
Re,ort of RU-486 vent
I (Required pursuant to R.C. 2119.1-2 )
I
1. Date RU-486 was provided: I/

I
I
I
Month Day Year
2. Name of medical practice or tfility at which RU-486 was provid d:
f l ~ .~ h-""J f i o-D rvp:
3. Address of medical practice or 1acility at which RU-486 was pro~i . ed:
a ,s-~ s-n .~ c~L .s , t) ~ flo

I
i'G] -fv tL!) ' : (
4. Date post RU-486 event began :

. . "/~-q-jJ l;J. .
.
~complete abortion 1-
I
Adverse reaction to RU-486 Patient hospitalized
Patient received a transfusion I- Severe bleeding
_ Other serious event (specify) ---...-----------+----------
6. Duration of ev~nt: ____Jz5

__ +ours _ _ 3_ Days
I
7. Remarks:

gal Department
3I E. Broad St., 3rd Floor
N j 13
olumbus, OH 43215-6127
Prescribed: 5//2011
j
slate Medical Board of Ohio

RePiort of RU-486 : vent
j (Required pursuant to R.C. 2119.12 .)
Ti be completed by the physician who provided , RU-486
'
I
I
I
Month Day Year
2. Name of medical practice or f1bility at which RU-486 was provid d:
.p ~ 1\ e::t, p~ ntco ~ 0 F- 6 ~---yl_; 0th 0

3. Address of medical practice or 1acility at which RU-486 was prov.i ed:
~ s3S1) (U)uU,1}~ ~ I
b~(U) ti-r3 OI-\ Lf ~ (~{p . ,
4. Date post RU-486 event begani
,11:!,Q/ ,~

I
I
5. Event(s) (Please check all that ipply):
_ Incomplete abortion 1- Adverse reaction to RU-486 Patient hospitalized
_ Patient received a transfusion I-

I
Severe bleeding
1
/other serious event (specify) _1.........
Mri_A4_nJ...,;M_t?nt.44
_ _ _.....,;..;..._..---&..;~~~.....,__-----..........r....'....../l.An--~o-rJ
6. Duration of event: L 1 ~ours _ _%_ Days

I
I '
7. Remarks:
8. a. Name of physician who provi~ec:t._-LD-t~""'

I
8. b. Physician's signature ! D.O

I
I ate __~-+-+-.J-++~---.--~------------~
~
1
Send completed forms to: State Medical scfard of Ohio
gal Department
3 E. Broad St., 3rc1 Floor
MEDI A SOARD
olumbus, OH 43215-6127
JN 4 2013
Prescribed: 5/.-/2011
State
I
Medical Board of- Ohio .
Re~ort of RU-486 :. vent
I (Required pursuant to R.C. 2119.12 -)
I .
Tr be completed by the physician who p~ovlded RU-486
iI
Month Day Year
2. Name of medical practice or f~bility at which RU-486 was provid d:

fGl-hJti~ P~'iT>too~ l op q/l,L~ OH,o
3. Address of medical practice or facility at which RU-486 was provi ed:

~ 5 3'51) i'l{)_G[/.,,S. I l) G 4 -
61fb rt) /Lb ff73 / 0 {1 ~ l.(- Jlf ~
. /0 / z_ -+--
.
I, a_ II
~complete abortion I- Adverse reaction to RU-486 Patient hospitalized
Patient received a transfusion 1-

I ,
Severe bleeding
_ Other serious event (specify) ----;.l_t__________.;i.---------

1
I
;
6. Duration of event: _ _Jo
__-_ ~ours __4
____ Days
i
7. Remarks:
8. a. Name of physician who provided RU-486 JJ

- I
8. b. Physician's signature - ~'~ -----1-~,......_~-+---#--;-~~---+---- M.D. / D.O
I
I '
Send completed forms to: State Medical B ard of Ohio ,
gal Department
l . 3, e. Broad St., 3rd Floor JA 4 201
I . .
rlumbus, OH 43215-6127
Prescribed: 5/-/2011
I.I
State
I
Medical Board. of Ohio
RePort of RU-486 vent
I (Required pursuant to R.C. 2119.12 )
I
Tj be completed by the physician who provided
I
RU-486
I
I

I
,() I
I
I
Month Year
2. Name of medical practice or tibility at which RU-48~ was provid .

f ~ ,~ ~ Plttk)-.Jnfoo~ Or g(L,e~ 6/-/,,r.J
3. Address of medical practice or facility at which RU-486 was provi ed:

~53Sb rt,ouL.S. tb~ rtlo
(2;.nro (Li) th-3, o H ~ 1+, u (p . ,

. . I
II} I \p.f t :J. !
5. Event(s) {Please check all that jpply):
I-
I-
_ Incomplete abortion Adverse reaction to RU-486 Patient hospitalized
Patient received a transfusion Severe bleeding
/other serious event {specify) ---""-+--;,:____.n

. . . . .()_"'--------....---------
.
f
1
!
6. Duration of ev~nt: _ _.()

_____ o~rs ll.f Days
I
Send completed forms to: State Medical Boa d of Ohio
gal Department
3. E. Broad St., 3rd Floor
I
MEDICAL
JAN 201
ARD
1. Date RU~486 was provided:

Id\ ll Jo1 L
Month Day Year
A~:+e-rM
}d--0C>D ~Ku- /3lvd . CJ-(v~~ DI+ '-/Lf l)._o

,1~1,)
~ complete abortion - Adverse reaction to RU-486 _ Patient hospitalized
~-r
6. Duration of event: 5R. Hours 7 Days
Send completed forms to: State Medica1Board of Ohio

Legal Department
ME I AL GARD
Columbus, OH 43215-6127 JAN .2 8 2013
Prescribed : 5/--/2011, Rev. 12/13/12


Month Day
lI
Year
ItM'l v\.l J l7ttreA!v~ N~s+-

l PJ'do~ ~ZUh1a fZ--4 ~ft;wt 67-r Cf 4IL/~

4. Date post RU-4~/0tegan:
l ~ I I
~ ncomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: y Hours Days
7. Remarks:

Legal Department
0
30 E ~r aM t.,
I O~ d~ Fwloor,l J z
P .,.
Columbus, Q.~ _43215-6127

0~ / v ~j - , ~ , -- - ~
f I


tl
Month Day Year
fllUMVJL f~ffl} .
tel Ga> i~ U , ~ ~ O}r lf~Jlf&

5. Event(s) (Please c all that apply):
/incomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: 2,::: Hours ____ Days
7. Remarksl)~{ rr~)tl0,r
Send completed forms\ to: State Medical Board of Ohio

' Legal Department
30 E. Broad St., F:I O~d 0 .. T Zi Z
Columbus, OH
State Medical Board of Ohio EiDIGAL BOARD
Report of RU-486 Event Nov 302012
To be complete<i by the physician who provided RU486

Day Year
io qc~
3. Address of medical practice or facility at wh ich RU-486 was provided :
I! ~55 { . tT /;/ 15. &f f'3 0

to(t L- \l v
5. Event(s) (Please check all that apply) :
~ m plete abortion ._ Adverse reaction to RU-486 _ Patient hospitalized
Patient rece ived a transfusion _ Severe bleeding
_ Other serious event (specify ) - - - - - - - - - - - - - - - - -- - - ~- -
6. Duration of event: l,,t.f Hours ~ Days
17. Remarks : -P\-

~~ 0d C ~
~~~~-
8. b. Physician 's signature /:rh~<--

~------+-~--1<'--~--------~-~ M.D.
oZe tv/1l / f ~
'
Send completed forms to : State Medical Board of Ohio ~
o
Legal Department C)
30 E. Broad St. , 3 rd Floor

Prescribed: 5/-/2011

Month Day
1:2.
Year
/Jr-{_4-e 1\111\
l~o-~ Sl.tuK-a- /!}\vd c_\-( tH'< OH t./<ll~

4. Date post RU-486 event 0an:
mI t><l 12-
~omplete abortion - Adverse reaction to RU-486 _ Patient hospitalized

'
z_
-----
Legal Department
E. Broad St., Floor
30 3rd
MEDICAL BOARD
SEP 2 4 2012
Prescribed : 5/--/2011

Month Day Year
4 ~ 4--c.r \,'\A...
\JDOO S~-cr 6lvd, tkv~ - or+ t_/q l~o

qfz/12.-

I
6. Duration of event: ;).. Hours Days
7. Remarks:
Mil>,,/,',.,- t?wf/.d;-) 6~;t.df 9/2f12 I v-o +,Aw t-_,ofi'cJ-/~.
8. a. Name of physician who pro~ :~.:
8. b. Physician's signature - - - - - - - - - - - - - - - - - - - - - - - - <{fvw)D.O

Legal Department
30 E. Broad St., 3rd Floor G BOA D
Columbus, OH 43215-6127 SEP 2 4 20\2
~state Medical Board of Ohio
Report of RU-486 Event MEDICALtsUAA
(Required pursuant to R.C . 2119.123) SEP 10 2012
f-
Month Day Year
~~ 1\ldmW,1- ~
3. Address of medical practice orJcJFility at which RU-486 was provided:
% - '(b~k ~
r
4. Date post -486 event b~r~(/ 1/
~ complete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: ---+-f-- Hours ____ Days
7. Remarks:
8. a. Name of physician who pro

Legal Department
30 E. Broad St. , 3rd Floor
IQ;/8

Month Day Year

a_ .~3-.SD fLo Cr[-~ ; .D (?'" rL-0
h ITT) rb !L1) f/-8 C, 1--/,5 ) 01-l 1f lf( <+ (p
(o---)1--1~
~complete abortion Adverse reaction to RU-486 _ Patient hospitalized

-
6. Duration of event: 11 Hours

' Days
17. Remarks:
8. a. Name of physician

Legal Department
Jl:J
lqu;-11 .J

(Required pursuant to R.C . 2119.123)

?At.2
Month Day Year
~o
/.vent(s) (Please check all that apply):
_ Incomplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: - - ~ - Hours ____ Days
7. Remarks:
Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Legal Department
30 E. Broad St., 3rd Floor JlJN 20,a
1. Date RU-486 was provided: 10 20 ,1
"
Month

Day Year
ffN Po
'-f- <f J t.f- (p
IC\ s-5a Yeo CAL~ 1 1) l2 ~, Jb @) Pu fLJ)I 01-{

IJ./ ?Jj1,
_ Incomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
L Other serious event (specify) ~ A-;-\) f'l1 ~
6. Duration of event: f Hours flJ Days
7. Remarks:
_$fl) ( Trj
/D.O

MEDICAL BOA D
Legal Department
30 E. Broad St., 3rd Floor JUN 19 Z012

Month Day Year
2. Name of m ~pical practice or facility at which RU-486 was provided:
. vaJ--f/l/f/L. tJ. fto .. 11~'5 . . -

JA~~ . ft 0 ~T/it~ ;"111 tf//f) fi/.Jtf/3

Olt -0 --; L
_ Incomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
Patient rece ived a transfusion ~ Severe bleeding
_ Other serious event (specify) - - -~ - - -- - - -- - - - -~ - - - -- -
6. Duration of event: Hours _ _ _ _ Days
7. Remarks:

Date- - ~[{15"-f-{-+-"-\l __.,.A_......
. ...;:;._
) ,_-- _ _ __

Legal Department
Prescribed: 5/-/20 11
1. Date RU-486 was provided: I,;i

Month Day Year
r?-1'1\18)

~53,_so fZo t.rl-~ 1.b e (L!)
~81)R>M HT3, of-\ lf4,r4.p

"'-1-,~
/incomplete aborti~n - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: t Hours {21" Days
7. Remarks:
8. a. Name of physician wh

Legal Department MEDICAL t30ARD
30 E. Broad St., 3rd Floor J 2012
1. Date RU-486 was provided: J ?-

Month Day Year

f :f tv f?LJ
~ 6"".; So /Lo ul.-S 1.b e l'LD
.~(?UrbM fh?l ~ ,-.f-n.l oH lftftl{-~
4. c;>ate post RU-486 event began:
(p-~-,~
~ncomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: I Hours f/ Days

.,
7. Remarks: DICALBOARD
IU~' 3 2012

Legal Department
30 E. Broad St., 3rc:t Floor
,


Month
~/
Day Year
2.
$)5'5 f ....
/iwr!J 5;/red j//1M~~ [)/;{) I/JL/3

/!-II/~
~ncomplete abortion _ Adverse reaction to AU-486 _ Patient hospitalized
- Patient ,received a transfusion _ Severe bleeding
_ Other serious event (specify) -
6. Duration of event Hours /Cf Days

I
7. Remarks:
8. a. Name of physician who provided RU .. 486
Send comp1eted forms to: State Medical Board of Ohio

Legal Department
Columbus, OH 43215-6127 l GAO
MAY l 2a1z
Prescribed: 5//2011
'-State Medical Board of ~io
1. Date RU-486 was provided: I KJ 2.o J J

Month Day Year

f-f ~ p-7)
\l ~ ~ ~L..S ,t,e- 1, et fb(W J tO Ii 4Lf I Lf ~

yL,o I
10/J<i/ JJ
_ Incomplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
~ e r serious event (specify) ~ /r,t) {Yl eTYl-lf-
6. Duration of event: 1 Hours ~ Days
7. Remarks:
8. a. Name of physiciar.1 who provide

Legal Department
5/ :z Hd 6Z AV ZIOZ 30 E. Broad St., 3rd Floor
Otl OJ O 0 Columbus, OH 43215-6127
V'OB lV':JIQ3 1 ilS
-~ tate Medical Board of tn-1io
1. Date RU-486 was provided: ,1 0 \

Month Day Year
f pt.J VJ
,qs-s-o ~ vtL~tb ~ fu, I

fb~Fb(U), oH 4Y-l lt le
4. (?ate post RU-486 event began:
111,r1,,
/incomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: t Hours y Days
7. Remarks:
8. a. Name of physician who provi

SI :z Jld Legal Department
6c A 1,/ l!OZ 30 E. Broad St., 3rd Floor
Ot1'r/oe FJHo .:Jo Columbus, OH 43215-6127 ICALBQA D
:J/OJH
.1. ::1s MAY 19 20f2
To be compl_eted by the physician who provided RU-486
1. Date RU-486 was provided: }~ () I
Month Day Year

f {J ~ e-"l)
Ji~ (l,v UL ...S I J) E' /lAJ I <8,t}i)fo;UJ I 0 I/ l.f '{--I t.f lo

1
i.,/ I 5' /JJ
/Incomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
-V:. ~ etl 1e1~1 ioas et1er 1t {sget:if~) tl F!:11 I ~ 6 ~ S l Jt ;14 .v~
6. Duration of event: fj Hours 13 Days
7. Remarks:
Send completed forms to: State Medical Boa of Ohio

Legal Department
S/ 2 U
. d 6c ~ i, l/Oz Columbus, OH 43215-6127 ICALBOARD
a~ 'V oe 701Ho .:10 MAY 2 9 2012
'tiJ/Q3
I
31 11 S
1
1. Date RU-486 was provided: CJ I I '7/

Month Day Year

ff "1 EC]
1q .5"5o -fl.o CIC - I I) 8 /U) . JbeDI

~J,1-/r2-
/Incomplete abortion - Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: ~ Hours % Days
7. Remarks: u.t

Legal Department
S/ :z Hd 62 ..(V l/OZ 30 E. Broad St., 3rd Floor
M DICAL BOARD
a~ttoa ioJ;?o}t 3 ''ls MAY 9 2012
To be completed by the physician who provided AU-486

2otL
Month Day Year
O):\,' o W
I3. Address of medi~al practic~ or facility ~t which RU-486 was p~~~ided:
~ o m plete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
_ Patient received a transfusion ~ Severe bleeding
_ Other serious event (specify) - - -~ - -- - -- - ~ - - - - -- - - - --
6. Duration of event _ __ _ Hours _ _ _ Days
7. Remarks:
8. a. Name of physician who provided RU .. 486 roffl ['(U. LIY110\.tt1)

8. b. Physician 's signature . . ~ - - ..... . . ... M.D./ D.O
Date q /I. tf/(7--
Legal Department
Columbus, OH 43215-6127 MAY 2 4 2012
Prescribed: 5H2011
----- - ..
To be completed by the physlcfan who provided RU-486
1. Date iRU-486 was provided:

\2.
Month
' Day Year
2. Name of medical practice or facility at which AU-486 was provided:
i.ss
:llto/1;..
_ _ 1ncomplete abortion _ Adverse reaction to RU-486 _ Patient hospitalized
__ Patient received a transfusion _ Severe bleeding
_x Other serious event (specify) - _ fn_ b_,_clu-abv

. -~
~ - -Utu/J
--......,'t)
r--1. ~,- - -- - - - - - - - - -
6. Duration of event _2__ Hours - - ~ Days
7. Remarks:
8. a. Name of physician who provided RU-486 - -fK-v-

e ~cLer.a. .wi,~
.V:::- - - - - -- -- - - -
8. b. Physician's signature - --;/}'1'--
..4.-.--h_~~ ~ - - - - -- - - - - - - M.D. / D.O
l Date 6/f/JJ- .
Send comp1eted forms to: State Medical Board of Ohio
Legal Department
30 E. Broad St, 3 rd Floor
fJO :g WV 12 AVWl IOZ
Columbus, OH 43215-6127 My - 201
OIHO :10
OHVOS l\13I03W 31VlS
Prescribed: 5//2011

3
Month Day Year
f{M~j p~~m- ~ -N ~ ~

~~ ,su ~Ll,04'\. ~ u
. l-tK CYl--\-
4. Date post RU-486 event begaT~/iv
~ Incomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _____ Hours ____ Days
7. Remarks:
8. a. Name of physician who p r o v i ~ 6 vu\,k r:, SVIAAfr

8. b. Physician's signature J , 1 M.D. I D.O
. ate S-/1(/Y
Legal Department
Report of RU:.486 Event
1. Date RU-486 was provided: " )

;-,
;,'
Month Day Year
2. Name of medical practice or facility at which RU-486 was prov!9ed:
lLvuu d 9{ 1 ~ ctSIY Dlvto

1/j~r:;t) Q.o{,W-Ad.e u Hf4 oH- LfLi.1l/b

4. Date post RU-486 eve t b gan:
if ; J'V
5. Event(s) {Please check al that apply):
v' Incomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _ _
/ _ Hours _ _ _ Days
7. Remarks:

Legal Department
30 E. Broad St., 3rd Floor EB
Columbus, OH 43215-6127 A,'{

8
Month Day Year
1/a_; rt<__re.flvThcro--d ~ . tt}yf\-- cJtu.0

~r;3~~~~ U
~ 6}+ L{l/ ( lf(c;
4. Date post RU-486 event began: / /
Lf 1 GI _(~-
~ ncomplete abortion Adverse reaction to RU-486 _ Patient hospitalized
6. Duration of event: _ _. . . ,1_/_ Hours ____ Days
7. Remarks:

Legal Department
ZO\

Month Day Year
l~vtV\UJl Ptu~dlrt1 ~~ 0
u~ro ~VLL/ldf ~ Wfu-1-H+s (){+ lf l/I c/0

4. ;7~7~486 event began:
6. Duration of event: L
7
Hours Days
7. Remarks:
8. a. Name of physician wh
8. b. Physician's signature . /D.O

Legal Department
30 E. Broad St., 3rd Floor APR - 5 2012
(Required pursuant to R.C . 2119.123)
1. (o 2,o l 2-
Month Day Year
2. Name of medic I practice or facility at which RU-486 was provided:

{J(llJt~A. ~~om) (J~ fJdV~~ )+ ()~ 0
3. Address of med cal practice or facility at which RU-486 was provided:
~~c;-D 4~ ~ ~ -0wi ~ 01+ L{<.{(L( (p
4. Date post RU-4i 6 event b.egan:

' '2A) l (~
5. Event(s) (Pleas : check all that apply):
~
_ Incomplete aborti n Adverse reaction to RU-486 _ Patient hospitalized
_ Other serious eve t (specify) - - - - - - - - - - - - - - - - - - - - - - -
6. Duration of eve t: ___I__ Hours ____ Days
7. Remarks:
8. a. Name of phys cian who p r o v i d ~ ~ E n /:. <;' WU-rlA

8. b. Physician's si nature 8bb------........,,,,
- - - ~......- ....- - - - - - - - - - - - M.D. / D.O
I Date _ _ _ 3_/;;_,~/t_'Z________
-- _
Send completed fo ms to: State Medical Board of Ohio
Legal Department

Ohio RU486 Event Reports 2012-2016

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Ohio RU486 Event Reports 2012-2016

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State Medical Board of Ohio

1. Date RU-486 was provided: / 2- I '3

23 tL{ ;A-LAhv.r/l /f-v-A. {Anei ' ,I

- Patient received a transfusion _ Severe bleeding

_ Other serious event (specify}

6. Duration of event: 3 Hours Days

,8. a. Name of physician who provided RU-486

18. b. Physician's signature - ~~ / ~DO

Send completed forms to: State Medical Board of Ohio

To be completed by the physician who provided RU-486

1. Date RU-486 was provided:

2. Name of medical practice or facility at which RU-486 was provided:

P) o.xu1uJ PllY-m +ho cl ~CLS+ S UYi c cc I

_ Incomplete abortion Adverse reaction to RU -486 _ Patient hospita li zed

Patient received a transfusion _ Severe bleed ing

8. a. Name of physician who provided RU-48/'\ A_= (I no ffiQflO

Send completed forms to: State Medical Board of Ohio

Prescribed: 5/--/2011, Rev. 12/13/12

To be completed by the physician who provided RU-486

1. Date RU-486 was provided:

2. Name of medical practice or facility at which RU-486 was provided:

231<-{ ft<A h vi'/, ;A-u-t. (Anc, ' ,;

Patient received a transfusion _ Severe bleeding

_ Other serious event {specify)

18. a. Name of physician who provided RU-486 /,v'r-f r

Date l?--/J'/1 J. '

1. Date RU-486 was provided:

2. Name of medical practice or facility at which RU-486 was provided:

23 tL{ ftu b vf/l ft..,u. {An t,t ' .,I

_ Incomp lete abortion

Patient rece ived a t ransfusion _ Severe bleeding

6. Duration of event: 3 Hours Days

,8. a. Name of physician who provided

18. b. Physician's signature

1. Date RU-48 6 w as provided: /0

2. Name of medical practice or facility at which RU-486 was provided:

fl ei,,, N rl f o.r ..e11f-~~cl

}-S I cf /tu t, t) ( vi ;+v-1' , ~ '/lu'

Patient received transfusion _ Severe bleeding

6. Duration of event: ~ Hours Days h,,,. ~ rd:,ry,,-cf7 k ~f'_;,j';,t,-

18. a. Name of physician who provided RU-486~~

Send completed forms to: State Medical Board of Ohio

Colu...vnl?LLS, OH.lO ll'32J3 i

4. Date post RU-486 complication began: l 1/IO/ 1u

5. Event(s) (Please check all that app ly):

~x Incomplete abortion _ Adverse reaction to RU-486

_ Patient received a transfus ion _ Severe bleed ing I

6. Duration of event: _ _ _ _ Hours _ ) _g...____ Days

Columbus, OH 43215-6127 MEDICAL BOARD

.;_:- ~-~\/>-,_ State Medical Board of Ohio

(Required pursuant to R.C. 2~19.123)

3. Address of medical practice or facility at which RU-486 was provided:

; 1, ;_s f. Cl{(\ Jt ColU#tkr

_ Incompl ete abortion Adverse reaction to RU-486 II_ Patient hospitalized

Patient received a transfusion _ Severe bleeding I

/o:he, serious event (specify) ___i.2_,._'/e:_d____M_l__d....._.,c_a_n_ffe'l__A_b_o'rn

6. Duration of event: _ _ _ _ Hours _ _

8. a. Name of physician who provided RU-486

Send completed forms to: State Medical Board of Ohio

Prescribed: S/-/2011, Rev. 12/13/12 NOY Jl 201

Tobetompleted by,the :P,liysfc1ali whofi:>i'ovit!ed :Ro"4s6

~-th~.- oC ~cec\~s- . C?~ .P :

Adverse r~a"Ctio11 -t o:RU48"6 Pattent. . .$.ptfaHzed

: :::.:,t~tf.\(s:ci/i_o:us,e.v~~t:t#;~.21i.v.}: ...... .___. ;. . . .;...,. =--' -;o---..;..:...;..;.....;..;,;.,. _..........;_..;._:...,,