Appointment Scheduling and Health Educator Contact Request

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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.
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Date* This field is required.
Date
Month
Day
Year
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Please enter your date of birth.* This field is required.
Date
Month
Day
Year
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Age
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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.
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Language
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County of Residence* This field is required.
Bledsoe, TN
Rhea, TN
Bradley, TN
Sequatchie, TN
Franklin, TN
Catoosa, GA
Grundy, TN
Dade, GA
Hamilton, TN
Murray, GA
Marion, TN
Walker, GA
McMinn, TN
Whitfield, GA
Meigs, TN
DeKalb, AL
Polk, TN
Jackson, AL
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Full Name* This field is required.
First Name
Last Name
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Request Type* This field is required.
Schedule an appointment
Speak with a Health Educator
Schedule an appointment and speak with a Health Educator
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Phone Number* This field is required. To schedule an appointment, a staff member MUST speak with you over the phone.
Please enter a valid phone number.
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Email* This field is required.If you do not have an email address, type none@none.com
example@example.com
Confirm Email (Confirmar correo electrónico)
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Preferred Method of Contact* This field is required.Choose all that apply. Please note: A staff member must speak with you on the phone to schedule an appointment.
Phone
Text
Email
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Choose the best day(s) and time frame(s) to contact you.* This field is required.Choose all that apply. All times are in the Eastern Time Zone.
Monday 9:00am-1:00pm
Monday 1:00pm-5:00pm
Tuesday 9:00am-1:00pm
Tuesday 1:00pm-5:00pm
Wednesday 9:00am-1:00pm
Wednesday 1:00pm-5:00pm
Thursday 9:00am-1:00pm
Thursday 1:00pm-5:00pm
Friday 9:00am-1:00pm
Friday 1:00pm-5:00pm
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Leave us a noteUse this space to include details about your request or questions you may have so we can be better prepared when we contact you.
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Large
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Ok
Ok
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Would you like to be signed up to receive our quarterly newsletter?* This field is required.
Yes, subscribe me to the newsletter.
No.
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