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CAYA Diaphragm Screening

CAYA Diaphragm Screening

HIPAA

Compliance

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    ATTENTION ALL PATIENTS INTERESTED IN CAYA

    1. If you have already decided that you are ready for a visit with one of our virtual providers and are in need of a prescription, please press NEXT to continue.
    2. If you are not yet ready to commit to Caya but would like to learn more, please text us at 725-228-8277 to speak with one of our knowledgeable staff members.
    3. If you already have a prescription but are having trouble getting it filled, we can also help. Please fill out this form instead: https://pci.jotform.com/form/252605218052045
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    • I previously used a small (60 mm) or large (85 mm, 90 mm) traditional sized diaphragm. • I am within the first six weeks after childbirth (a medical check-up is recommended). • I am within the first six weeks after a second trimester abortion or miscarriage. • I have poor or absent pelvic floor muscle tone. • I have a pronounced cystocele (bladder prolapse), uterine prolapse or rectocele. • I have an acute urinary tract infection. • I have a history of recurring urinary tract infections. • I have an acute infection of the genital organs and/or minor pelvis. • I have a history of toxic shock syndrome TSS (very rare). • I have known allergy to sorbic acid/ sorbate (very rare). • I am at risk of HIV infection or has acquired HIV (Caya® diaphragm does not protect against HIV). • I have been told by an OBGYN that I have a “tilted or retroverted uterus"
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    (If different from billing address) Please fill out the shipping address below you want the Caya product to be mailed to.
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    • Algeria
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    • Andorra
    • Angola
    • Anguilla
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    • Burundi
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    • Chad
    • Chile
    • China
    • Christmas Island
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    • Congo
    • Cook Islands
    • Costa Rica
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    • Cuba
    • Curaçao
    • Cyprus
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    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
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    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
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    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
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    • Sudan
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    • Svalbard
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    • Sweden
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    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
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    • Wallis and Futuna
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  • 16

    Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app. Available now on Android phones/tablets from the Google Play Store. Click here to download https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US

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  • 17
    A $25 admin fee will apply for every submission. The Dr. visit fee can be billed using insurance if we are participating with your insurance carrier. Self Pay Patients or Out Of Network Insurance patients will pay an additional fee of $40 dollars to cover the cost of the visit making the total $65.00. If you have questions in regards to your Insurance Network Participation status or any other billing inquiry please contact the office by Text: 725 228 8277 Phone: 888 224 0804 or Email:Billing@myvirtualphysician.com
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  • 18
    Your CAYA prescription will by default be sent to the Tampa Specialty Pharmacy, please contact Tampa Specialty Pharmacy at (813)644-7277 for pricing inquiries. Please note that pricing for the prescription is set by your insurance company and cannot be adjusted by My Virtual Physician. For any questions or other inquiries regarding the CAYA diaphragm or other methods of contraception, please contact My Virtual Physician at 888-224-0804
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    • CAYA Diaphragm Co-Pay
      CAYA Diaphragm Co-PayAdmin fee for Caya booking
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      • Argentina
      • Armenia
      • Aruba
      • Australia
      • Austria
      • Azerbaijan
      • The Bahamas
      • Bahrain
      • Bangladesh
      • Barbados
      • Belarus
      • Belgium
      • Belize
      • Benin
      • Bermuda
      • Bhutan
      • Bolivia
      • Bosnia and Herzegovina
      • Botswana
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      • Brunei
      • Bulgaria
      • Burkina Faso
      • Burundi
      • Cambodia
      • Cameroon
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      • Central African Republic
      • Chad
      • Chile
      • China
      • Christmas Island
      • Cocos (Keeling) Islands
      • Colombia
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      • Congo
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      • Cote d'Ivoire
      • Croatia
      • Cuba
      • Curaçao
      • Cyprus
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      • Denmark
      • Djibouti
      • Dominica
      • Dominican Republic
      • Ecuador
      • Egypt
      • El Salvador
      • Equatorial Guinea
      • Eritrea
      • Estonia
      • Ethiopia
      • Falkland Islands
      • Faroe Islands
      • Fiji
      • Finland
      • France
      • French Polynesia
      • Gabon
      • The Gambia
      • Georgia
      • Germany
      • Ghana
      • Gibraltar
      • Greece
      • Greenland
      • Grenada
      • Guadeloupe
      • Guam
      • Guatemala
      • Guernsey
      • Guinea
      • Guinea-Bissau
      • Guyana
      • Haiti
      • Honduras
      • Hong Kong
      • Hungary
      • Iceland
      • India
      • Indonesia
      • Iran
      • Iraq
      • Ireland
      • Israel
      • Italy
      • Jamaica
      • Japan
      • Jersey
      • Jordan
      • Kazakhstan
      • Kenya
      • Kiribati
      • North Korea
      • South Korea
      • Kosovo
      • Kuwait
      • Kyrgyzstan
      • Laos
      • Latvia
      • Lebanon
      • Lesotho
      • Liberia
      • Libya
      • Liechtenstein
      • Lithuania
      • Luxembourg
      • Macau
      • Macedonia
      • Madagascar
      • Malawi
      • Malaysia
      • Maldives
      • Mali
      • Malta
      • Marshall Islands
      • Martinique
      • Mauritania
      • Mauritius
      • Mayotte
      • Mexico
      • Micronesia
      • Moldova
      • Monaco
      • Mongolia
      • Montenegro
      • Montserrat
      • Morocco
      • Mozambique
      • Myanmar
      • Nagorno-Karabakh
      • Namibia
      • Nauru
      • Nepal
      • Netherlands
      • Netherlands Antilles
      • New Caledonia
      • New Zealand
      • Nicaragua
      • Niger
      • Nigeria
      • Niue
      • Norfolk Island
      • Turkish Republic of Northern Cyprus
      • Northern Mariana
      • Norway
      • Oman
      • Pakistan
      • Palau
      • Palestine
      • Panama
      • Papua New Guinea
      • Paraguay
      • Peru
      • Philippines
      • Pitcairn Islands
      • Poland
      • Portugal
      • Puerto Rico
      • Qatar
      • Republic of the Congo
      • Romania
      • Russia
      • Rwanda
      • Saint Barthelemy
      • Saint Helena
      • Saint Kitts and Nevis
      • Saint Lucia
      • Saint Martin
      • Saint Pierre and Miquelon
      • Saint Vincent and the Grenadines
      • Samoa
      • San Marino
      • Sao Tome and Principe
      • Saudi Arabia
      • Senegal
      • Serbia
      • Seychelles
      • Sierra Leone
      • Singapore
      • Slovakia
      • Slovenia
      • Solomon Islands
      • Somalia
      • Somaliland
      • South Africa
      • South Ossetia
      • South Sudan
      • Spain
      • Sri Lanka
      • Sudan
      • Suriname
      • Svalbard
      • eSwatini
      • Sweden
      • Switzerland
      • Syria
      • Taiwan
      • Tajikistan
      • Tanzania
      • Thailand
      • Timor-Leste
      • Togo
      • Tokelau
      • Tonga
      • Transnistria Pridnestrovie
      • Trinidad and Tobago
      • Tristan da Cunha
      • Tunisia
      • Turkey
      • Turkmenistan
      • Turks and Caicos Islands
      • Tuvalu
      • Uganda
      • Ukraine
      • United Arab Emirates
      • United Kingdom
      • United States
      • Uruguay
      • Uzbekistan
      • Vanuatu
      • Vatican City
      • Venezuela
      • Vietnam
      • British Virgin Islands
      • Isle of Man
      • US Virgin Islands
      • Wallis and Futuna
      • Western Sahara
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