Medication Abortion Eligibility & Telehealth Intake Questionnaire
Please complete this brief intake to help us determine your eligibility for medication abortion via telehealth. All questions are required to ensure safe and effective care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
Date of Last Menstrual Period (LMP)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently experiencing any of the following? (Select all that apply)
*
Heavy vaginal bleeding
Severe abdominal pain
Fever or chills
None of the above
Do you have any of the following health conditions? (Select all that apply)
*
Allergy to mifepristone or misoprostol
Bleeding disorder
Chronic adrenal failure
Porphyria
None of the above
Are you currently taking any medications? If yes, please list them.
Is there anything else you would like our care team to know?
Submit
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