Hope Clinic - Telehealth Form

1

Do you live in Illinois?* This field is required.

YESNO

2

Are you certain that you are LESS than 8 weeks in pregnancy? * This field is required.(By an ultrasound in this pregnancy or by knowing the FIRST DAY of your most recent period was less than 8 weeks ago)

YESNO

3

Are you interested in an appointment over the phone/video instead of a visit in person at the clinic?* This field is required.In most cases, you would not require an ultrasound or any lab work.

YESNO

4

We apologize, we cannot schedule you online at this time. Press submit to be redirected to our regular appointment page or you can call our office (618) 451-5722