Birth Control Request

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Please enter the following information so we know if we have doctors available for you.
What state are you requesting treatment in? *

Sorry, but we don't have any doctors available in that state right now.

If you continue to fill out this form, we will not be able to complete your medication request. We are working hard to add more doctors to our team!

Before continuing, please agree and accept the Terms and Conditions so we are able to properly handle your health information.
Full Name *

First Name Middle Name (optional) Last Name
Date *

Month Day Year
This field is locked by default.
Please accept the following agreements so we can proceed with your medical visit. *

I agree to the Privacy Policy , Terms and conditions , and Telehealth Consent .
Please sign below with your mouse or touchscreen. *

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Let us get to know you.

The following information is going to help us qualify you and give you the best treatment possible.
What is your Full Name? *

First Name Middle Name (optional) Last Name
What is your phone number? *

Area Code Phone Number
What is your Date of Birth? *

Month Day Year
Select your Sex, we'll make sure you qualify for this treatment. *

Male Female
Please enter your height. (Inches) *
Please enter your weight. (Lbs) *
What is your Address? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is this also your billing address? *

Yes No
Email *

Confirmation Email It's crucial we have the correct email for your account.

Birth Control Request

Please give us some more information so we can process your request and match you with a doctor.
What type of Birth Control are you requesting evaluation for? *
Please choose which option we can help you with.
Are you currently using any birth control methods now? This includes IUDs, condoms, or any other method you may use. *

Yes No
What birth control methods are you currently using? *
Please include all methods such as IUDs and condoms.
How long have you been using these birth control methods? *
Have you missed any doses of your current birth control this month? *

Yes No
What can we help you do today? *

Refill my current Birth Control method Change to a different type of birth control

What was the date of the first day of your last menstrual period (date you started bleeding)?
How often do you get your menstrual periods? *
How would you describe your gender identity? *

Male Female Non-Binary
Do you know your blood pressure from a recently taken reading (6 months or earlier)? We need a recent and accurate reading to figure out what treatment options are safe for you. If you don't have a reading right now we will tell you how to get it and you can send it later. *

Yes No
What was your blood pressure at last reading? This should be two numbers. Carefully type the top (systolic) and bottom (diastolic) readings. Please enter your reading carefully, it is very important to treat you safely.

Last step!

We just need a little more information
Have you ever had migraine headaches? Even if they only occurred when you were younger it is important for us to know because they can increase some serious risks with certain types of birth control. *

Yes No, never had migraines
Will you use insurance to help pay for your medicine? You can use your insurance at the pharmacy, or if you don't have insurance we can help you find low cost options. *

Yes No, don't have insurance No, I don't want to use insurance I'm not sure

Checkout Time!

Once your payment is processed and the form is submitted a doctor will reach out to you shortly!
Birth Control Appointment
prev next ( X )
Birth Control Medicine Appointment
$ 0.10

Total

$ 0.00
Uploading a Photo of your ID will help us confirm your identity and make it easier for us to give you treatment. (Optional)

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What is your Billing Address? *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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