Appointment Scheduling and Health Educator Contact Request

To request free birth control pills without receiving a callback from a staff member, you can visit this link to fill out an intake form. If you would like to speak to a staff member, please continue filling out this form.

Our service area includes the following 18 counties:

If you do not live or go to school in our 18-county service area, you can reach out to your local health department for additional information and resources.
Date*

MonthDayYear
Date
Please enter your date of birth.*

MonthDayYear
Date
Age
Per state law, since you are under the age of 18, you will need to have a parent or guardian present when a Health Educator contacts you. Since we must verify a parent or guardian is present, we cannot provide information via text message.

If you would like to schedule an appointment, you will need a parent or guardian present during the call to our appointment line.
Language
County of Residence*

Bledsoe, TNRhea, TNBradley, TNSequatchie, TNFranklin, TNCatoosa, GAGrundy, TNDade, GAHamilton, TNMurray, GAMarion, TNWalker, GAMcMinn, TNWhitfield, GAMeigs, TNDeKalb, ALPolk, TNJackson, AL
Full Name*

First NameLast Name
Request Type*

Schedule an appointmentSpeak with a Health EducatorSchedule an appointment and speak with a Health Educator
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Preferred Method of Contact*

PhoneTextEmail
Choose the best day(s) and time frame(s) to contact you.*

Monday 9:00am-1:00pmMonday 1:00pm-5:00pmTuesday 9:00am-1:00pmTuesday 1:00pm-5:00pmWednesday 9:00am-1:00pmWednesday 1:00pm-5:00pmThursday 9:00am-1:00pmThursday 1:00pm-5:00pmFriday 9:00am-1:00pmFriday 1:00pm-5:00pm
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Use the link below to schedule with our Nurse Navigator:

Nurse Navigator phone appointments
Should be Empty: