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Confidential patient intake

Help a licensed provider review your request safely.

Please answer as accurately as you can. This form helps determine whether medication abortion telehealth care may be medically appropriate and legally available for your situation.

1

Patient basics

Confirm age, date of birth, and current location for eligibility review.

2

Pregnancy information

These questions help estimate timing and screen for urgent concerns.

Have you had a positive pregnancy test?
Have you ever had an ectopic pregnancy?
Do you currently have an IUD in place?
Are you having severe pelvic pain or heavy bleeding?
3

Medical history

List allergies, medications, and medical conditions for provider review.

4

Contact and shipping

Provide contact details and the address where pharmacy shipment may be sent if appropriate.

5

Consent and acknowledgements

Please confirm before submitting your confidential intake.