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Please take your time submitting accurate medical information. It is used to create a formal medical record in our system. Intake should take 10-15 minutes. Only patients should submit information for themselves. 
Please take your time submitting accurate medical information. It is used to create a formal medical record in our system. Intake should take 10-15 minutes. Only patients should submit information for themselves. 
Abortion on Demand is ideal for people who are certain they wish to end their pregnancies with pills by mail. For more in-depth counseling services please see our resources page. To get started, we first need to get some information about your pregnancy. Everything you tell us is secure and private. It should take about 10 minutes. This is part of your formal medical record, so please take your time to provide accurate information. ONLY YOU should book an appointment FOR YOURSELF.
AOD - Intake Form
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    Software used during your video appointment will confirm your location for regulatory compliance.
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    We will need to see your photo ID with date of birth during your virtual appointment. If you do not have an ID, please see our resources page for other care options.
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    We need to do a secure video consultation then be able to reach you if needed after your appointment.
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    There are many things other than pregnancy that can cause missed periods.
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    The only exceptions to the following location requirement are patients seeking care from Pennsylvania picking up medications in Maryland or New Jersey OR patients in Washington, D.C. picking up medications in Maryland or Virginia.
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    We rely on patients self-reporting accurate medical history to ensure safe abortion care. By proceeding you understand that this intake is used to create your formal medical record and you agree to provide accurate medical information. You understand that - due to the remote nature of our service - we may not permit repeat intakes with varying information, even if entered in error. Only prospective patients may submit their own intakes. You are not permitted to submit medical information for someone other than yourself. We review each scheduled appointment for safety and legal compliance. If safety or legal concerns arise, we may refer you to another care provider.
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    Most people do not need an ultrasound for early abortion care. If you had an ultrasound for this pregnancy it would have been reported to you based on the number of weeks into your pregnancy you were and/or your expected due date if you were to continue the pregnancy. The doctor may ask to see the report during your visit.
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    Leave blank if you do not know the due date.
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    Leave blank if you don't know.
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    Please select the option that fits best.
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    These are pregnancies outside of the uterus, sometimes called a tubal pregnancy.
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    These are also known as tubal pregnancies and are a medical emergency.
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    Please leave this blank or click NEXT.
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    Pelvic inflammatory disease is an infection in the uterus, ovaries and/or fallopian tubes most commonly caused by sexually transmitted infections.
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    An intrauterine device (IUD) is a small device that is placed inside the uterus to prevent pregnancy.
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    More information about NSAIDs, Prostaglandins and Mifepristone is on our FAQ page.
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    More details about these rare conditions can be found on our FAQ page.
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    Please leave this blank or click NEXT
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    We have partnered with SAFE Maine (safemaine.org) to offer financial assistance to Mainers who are unable to pay the full cost of their abortion care. Please consider donating at safemaine.org if you are able to pay full price and want to help other Mainers.
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    We work directly with abortion funds to help reduce financial burdens whenever possible.
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    AOD can offer a lower $239 fee for patients in need.

     

    Please check you email confirmation after scheduling your appointment time for further financial assistance options. Payment is due at the time of service. 

    Click NEXT to proceed.

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    We’re almost ready to get you scheduled with one of our experienced clinicians. There are some confidential questions we are legally required to ask. Though we have to ask, you do not have to answer. The following questions will in no way affect your ability to get care with AOD. You may leave them blank if you wish.

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    No podemos brindar atención en español de manera segura en este momento. Consulte nuestra página de recursos para conocer las opciones de atención en español.

     

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    You can leave blank if you do not have a PCP or do not wish to provide this information.
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    (12 = high school)
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    You may leave blank/skip if you do not wish to answer.
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    You may skip this question if you do not wish to answer.
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    You may skip this question if you do not wish to answer.
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    We only offer appointments in English at this time. We must be able to speak directly with patients in English. Family members and partners cannot serve as interpreters due to anti-coercion laws. This question is part of abortion reporting required by the state of Connecticut.
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    Thanks for that information.

    Now let’s get you scheduled with one of our experienced clinicians.

    Sunday and evening appointments are available for convenience. But all medication packets are shipped out overnight Monday-Friday approximiately 5pm Eastern time after the video visit is completed. Most visits take about 15 minutes.

    We have noticed an increase in patients since news about the Supreme Court leak. We are working hard to accomodate a high demand of appointment requests. Please do not call requesting an earlier appointment. Our scheduling system will show you the earliest appointment available.

    For patients in Georgia and Minnesota, we must delay sending the order to our pharmacy partner by 24 hours due to legally-mandated waiting periods in those states.

    Payment is due at the time of the appointment. We cannot hold medication packages for more than 2 days for delayed payment. If you are in need of funding assistance from the options on our resources page, please give yourself a few extra buffer days to schedule your visit.

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    Your name as it appears on your ID.
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    You must be over 18, and you will have to present your ID during your visit for additional age and identify verification.
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    This is where your medication abortion kit will be sent after your appointment. It MUST be a valid residential address in the SAME state as your intake. We cannot ship to P.O. boxes, business addresses or shipment centers. Do NOT give an address that is not a RESIDENCE. We will CANCEL any appointments made using a shipping center or post office, and you will not be permitted to use our service in the future. Thank you for your understanding.
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    • Meeker
    • Mille Lacs
    • Morrison
    • Mower
    • Murray
    • Nicollet
    • Nobles
    • Norman
    • Olmsted
    • Otter Tail
    • Pennington
    • Pine
    • Pipestone
    • Polk
    • Pope
    • Ramsey
    • Red Lake
    • Redwood
    • Renville
    • Rice
    • Rock
    • Roseau
    • Saint Louis
    • Scott
    • Sherburne
    • Sibley
    • Stearns
    • Steele
    • Stevens
    • Swift
    • Todd
    • Traverse
    • Wabasha
    • Wadena
    • Waseca
    • Washington
    • Watonwan
    • Wilkin
    • Winona
    • Wright
    • Yellow Medicine
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    This does not alter your ability to get care with AOD in any way.
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    AOD will send scheduling reminders and medication information to this account. It should be an email ONLY YOU can access. The verification code will be sent from noreply@jotform.com - be sure to check your spam folder. We have had recent issues with yahoo email accounts and would recommend using a service other than yahoo.
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    Please enter your cell phone number. You'll get a confirmation code from AOD shortly. Message and data rates apply.
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    select all that apply
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    Limited Availablity for Georgia patients

    Please note in light of the recent Supreme Court ruling overturning Roe v Wade, we are winding down our services for patients in Georgia. We have very limited appointment availability between now and July 15, 2022 when we will close our practice in Georgia. 

    Appointments are first-come, first-serve. We recommend selecting an appointment time you can keep. Rescheduling or failing to show for your scheduled appointment could mean we may refer you out-of-state. 

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    Telemedicine Consent


    Today you are requesting Abortion On Demand’s telemedicine services (“Services”). Telemedicine is the practice of medicine that involves the use of electronic communications to diagnose or treat patients who are in different locations than their healthcare providers. When using these Services you will be treated by and enter into a patient-clinician relationship with a clinician licensed in your state.


    The expected benefits of using telemedicine for your abortion care include:

    • Improved and quicker access to medical care through reduced travel and visit time.
    • Ability to access care from any location in your state, provided it is a state in which Services are offered.
    • More efficient medical evaluation and management.

    The potential limitations associated with using telemedicine for abortion care include:

    • Delays in medical evaluation and treatment due to failures in technology, such as power outages and disconnected internet.
    • Information may be lost due to technical failures.
    • Despite reasonable precautions, unauthorized persons could interrupt the transmission or electronic storage of your medical information.
    • In rare cases, a lack of access to complete medical information may result in adverse drug interactions, allergic reactions, or other complications including undiagnosed or delayed diagnosis of ectopic pregnancy and maternal alloimmunization. 

    The inability to have direct, physical contact with your healthcare provider is the primary difference between telemedicine and in-person health care. The alternative to telemedicine is receiving care in a traditional in-person care setting. Traditional in-person care for abortion may include ultrasound diagnosis for confirming gestational age, confirming pregnancy location and to rule out ectopic pregnancy; laboratory testing as indicated, and the option for surgical management of your abortion.


    Abortion On Demand uses the services of American Mail Order Pharmacy for dispensing medications. You may opt to use a different pharmacy of your choosing for medications other than mifepristone by notifying the clinician during your appointment. Whereas American Mail Order Pharmacy exclusively manages, stores, and ships mifepristone on behalf of the healthcare provider, another pharmacy cannot be used for shipping mifepristone.


    In receiving the telemedicine Services, you understand and agree:

    1. It is necessary for you to provide complete and accurate medical history. Providing inaccurate history can result in serious complications. 
    2. You cannot use our telemedicine Services for care beyond the scope of first-trimester medication abortion. We do not offer prescriptions for DEA controlled substances.
    3. You cannot use telemedicine Services for life-threatening emergencies. If you think you are experiencing a medical emergency, you need to call 911 or go immediately to the closest emergency room. 
    4. There is no guarantee that you will be treated by a clinician. The clinician reserves the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the clinician, the provision of the services is not medically or ethically appropriate.
    5. You understand that a variety of alternative methods of medical care may be available to you and that you may choose one or more of these at any time. These include in-person medication abortion, surgical abortion, parenting, or adoption.
    6. You understand that you have the right to withhold or withdraw your consent to the use of telemedicine in the course of your care at any time, without affecting your right to future care or treatment. 
    7. You have the right to receive medication counseling from a pharmacist directly, and you may notify the clinician during your visit if you wish to exercise this right.
    8. You will be required to provide full payment prior to receiving medications. You understand that other payment models for abortion care are available including health insurance, but that these options are beyond the scope of this Service. Refunds cannot be provided after medications have been shipped.
    9. You consent to use text and personal email to communicate about your care with Abortion On Demand. SMS and data charges may apply, depending on your carrier. You may contact info@abortionondemand.org to opt-out of SMS notifications. Email sent from Abortion On Demand is encrypted to meet federal privacy standards. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. You should not include personal identifying information such as your birth date or personal medical information in any emails you send to us. 

    Your use of this service is voluntary and you have the right to withdraw your consent to the services at any time. If you choose to end your session or cancel your appointment, your right to future telemedicine Services will not be affected. Information collected and stored in the medical record may be used in the future for quality improvement or other research purposes. All information will be anonymous; your personal information will not be used or shared without your consent.

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    If you are not sure, please see our resources page for other care options. You will be redirected to our secure scheduling page for booking.
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