Emergency Contraception Request Form / Formulario de Solicitud de Anticonceptivo de Emergencia

Please select language in the upper right corner / Por favor elige su idioma en la esquina de arriba a la derecha

Emergency Contraception Request Form

If you live in the Gulf South (Louisiana, Texas, Mississippi, Arkansas, Florida, or other Gulf South states) and are requesting emergency contraception (also known as "EC" "Plan B" or the "morning after pill") please fill out the following form. This is not an emergency service. Your package will be mailed within two weeks of receiving the request, in a package from a P.O. Box. PLEASE NOTE: EC can help prevent pregnancy if taken within 72 hours after unprotected sex. It is more effective the sooner it is taken. EC is considered to be less effective for people over 160 lbs. The packages normally contain two (2) doses of emergency contraception, condoms, pregnancy tests, and informational materials. Contents may vary based on availability of supplies but will always include two (2) doses of EC. We aim to ship packages within two weeks, but due to high demand it may take up to 4-6 weeks to receive your package. *Occasionally packages are returned to sender. As an all-volunteer collective, we appreciate your help in letting us know if you don't receive your package! If you don't receive your package within 6 weeks, please email us at gulfsouthplanb@protonmail.com & we can look into resending.*
Learn more about us at: gulfsouthplanb.com
Language/Idioma
Name*

First NameLast Name
Mailing Address (please note at this time we are only shipping to addresses in LA, TX, MS, FL, and AR)*

Mailing Address

Address Line 2

CityState

Zip Code
Phone Number (not required, but helpful if there is an error in the form and we need to contact you)
Please enter a valid phone number.
Email (not required, but helpful if there is an error in the form and we need to contact you)
example@example.com
How did you hear about us? Please be as detailed as possible, we love to know how the word is being spread! *
Please understand that we will only ship a package to an address once every 4 months. Please click that you understand.*

Yes, I understand.
Please understand that we are an all-volunteer group of individuals, and there may be a time when we do not have emergency contraception in stock. If this is the case, you will receive an email communication that we currently cannot assist. Please click that you understand.*

Yes, I understand.
Emergency contraception is NOT an abortion pill. It will not impact an existing pregnancy. Please click that you understand.*

Yes, I understand.
Do we have your permission to include resources about other reproductive care in your package?*

YesNo
Do you have any questions or feedback for us? Feel free to leave it here. If it requires a response, please ensure you've left your email address for us to contact you. Thank you.
Do you know of a community group anywhere in the Gulf South who would like to partner to distribute Plan B? If it requires a response, please ensure you've left your email address for us to contact you. Thank you & take care.
Should be Empty:

Emergency Contraception Request Form

Learn more about us at: gulfsouthplanb.com