ParaGard Intake Form

Did you have a ParaGard IUD implanted? *

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Has your ParaGard IUD been removed? *

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Did your ParaGard IUD Break? *

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In what year did your Paragard IUD break? *

To learn more about your options, submit your information below and we will send you our Paragard Informational Packet.

Thanks for answering our quick questionnaire, but you may not qualify.

However, if you are interested in learning more about recent Paragard studies, submit your info below and you will receive a FREE Paragard Information Packet.

First Name *

Last Name

Phone Number *

Email *

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Submitting this information DOES NOT create an attorney client relationship. By submitting this form, you agree to receive recurring text messages that may be sent by an autodialer. Consent is not a condition of purchasing goods or services. *

Yes