CAYA Diaphragm Screening

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Please select Yes or No if you have experienced any of the following:* This field is required.• 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"
Yes, I have experienced one of the listed items.No, I have not experienced any of the listed items.
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If you answered Yes to any of the items on the list:
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Date* This field is required.
Date
Month
Day
Year
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Phone number
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E-mail* This field is required.
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Birth Date* This field is required.
Month
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Year
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Billing Address* This field is required..
Street Address
Street Address Line 2
City
State
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United States
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Mongolia
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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
Yemen
Zambia
Zimbabwe
Other
Country
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Shipping Address(If different from billing address) Please fill out the shipping address below you want the Caya product to be mailed to.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
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
Yemen
Zambia
Zimbabwe
Other
Country
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Please enter your preferred language below. (optional)
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Do you have insurance?* This field is required.
YESNO
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If using insurance, upload a photo of your insurance card (front/back)* This field is required.
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Max. file size: 10.6MB
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Please enter your insurance information* This field is required.
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Please upload a photo of your ID (front/back)* This field is required.
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Max. file size: 10.6MB
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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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Payment Disclosure* This field is required.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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Signature* This field is required. 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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