New Version Aria Intake Form

1
Are you the person who will get the abortion?* This field is required.
Yes
No, I am scheduling for someone else
2
Patients should schedule their OWN appointments. You can share our website with the patient and help them schedule, but do not submit medical information for someone other than yourself. This is to ensure safety and quality care.
3
Date of Birth* This field is required.
as listed on your photo ID
Month
Day
Year
4
Qualifying age
5
We are sorry, we can only serve people 18 years and over.

You have many options:

Aid Access can mail pills to your home address, in all 50 states.

Trust Women and Planned Parenthood see people under the age of 18.

The State of Kansas requires parents to sign notarized consent forms in order for a minor to get an abortion. It may be easier to easier to get care in New Mexico, Illinois or Minnesota because these states do not have parental consent laws.

For more help, call:

If/When/How Judical Bypass Helpline (844) 868-2812

Jane's Due Process (866) 999-5263 helps minors from Texas get abortion care.
6
The next two questions help us know if you need help covering the cost of your abortion. If you skip the questions, the cost is $490.
7
In which state do you live?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KANSAS
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Canada
8
What is your zip code?* This field is required.
9
How many people live in your household?
Please Select
Please Select
1 (just me)
2
3
4
5
6
7
8
more than 8
10
Do you make less than $16,572 in a year ($1,381 in a month)?* This field is required.
Yes, I make LESS than $16,572 in a year.
No, I make MORE than $16,572 in a year.
11
Do you make less than $16,572 in a year ($1,381 in a month)?* This field is required.
Yes, I make LESS than $16,572 in a year.
No, I make MORE than $16,572 in a year.
12
Do you make less than $22,488 in a year ($1,874 in a month)?* This field is required.
Yes, I make LESS than $22,488 in a year.
No, I make MORE than $22,488 in a year.
13
Do you make less than $22,488 in a year ($1,874 in a month)?* This field is required.
Yes, I make LESS than $22,488 in a year.
No, I make MORE than $22,488 in a year.
14
Do you make less than $28,404 in a year ($2,367 in a month)?* This field is required.
Yes, I make LESS than $28,404 in a year.
No, I make MORE than $28,404 in a year.
15
Do you make less than $28,404 in a year ($2,367 in a month)?* This field is required.
Yes, I make LESS than $28,404 in a year.
No, I make MORE than $28,404 in a year.
16
Do you make less than $34,320 in a year ($2,860 in a month)?* This field is required.
Yes, I make LESS than $34,320 in a year.
No, I make MORE than $34,320 in a year.
17
Do you make less than $34,320 in a year ($2,860 in a month)?* This field is required.
Yes, I make LESS than $34,320 in a year.
No, I make MORE than $34,320 in a year.
18
Do you make less than $40,236 in a year ($3,353 in a month)?* This field is required.
Yes, I make LESS than $40,236 in a year.
No, I make MORE than $40,236 in a year.
19
Do you make less than $40,236 in a year ($3,353 in a month)?* This field is required.
Yes, I make LESS than $40,236 in a year.
No, I make MORE than $40,236 in a year.
20
Do you make less than $46,152 in a year ($3,846 in a month)?* This field is required.
Yes, I make LESS than $46,152 in a year.
No, I make MORE than $46,152 in a year.
21
Do you make less than $46,152 in a year ($3,846 in a month)?* This field is required.
Yes, I make LESS than $46,152 in a year.
No, I make MORE than $46,152 in a year.
22
Do you make less than $52,068 in a year ($4,339 in a month)?* This field is required.
Yes, I make LESS than $52,068 in a year.
No, I make MORE than $52,068 in a year.
23
Do you make less than $52,068 in a year ($4,339 in a month)?* This field is required.
Yes, I make LESS than $52,068 in a year.
No, I make MORE than $52,068 in a year.
24
Do you make less than $57,984 in a year ($4,832 in a month)?* This field is required.
Yes, I make LESS than $57,984 in a year.
No, I make MORE than $57,984 in a year.
25
Do you make less than $57,984 in a year ($4,832 in a month)?* This field is required.
Yes, I make LESS than $57,984 in a year.
No, I make MORE than $57,984 in a year.
26
Unique ID
27
Ban state?
28
Financial need?
29
Fund
Please Select
Please Select
none
TAF
NAF
NAF_plus_Sliding_Scale
NAF_plus_KAF
MOAF_fully_funded
MOAF_Sliding_Scale
AASN_fully_funded
AASN_Sliding_Scale
30
The cost of your abortion at Aria Medical is $490.

If this is a hardship, Medicaid covers abortion in your home state – you can go to abortionfinder.org if you would like to find a clinic in your state. You can also go to ineedana.com to search by zip code.
31
The cost of your abortion at Aria Medical is $490, $295 or $45, sliding scale. We accept Cash App, major credit cards, debit cards, and also cash.

The fee includes everything: the doctor visit, all medications, and an ultrasound (if needed).

You choose the cost you can afford. If the price is a hardship for you, Aria Medical works with donors to cover part or all of your visit.
32
The cost of your abortion at Aria Medical is $245 or $45, sliding scale.

We accept Cash App, major credit cards, debit cards, and also cash.

The fee includes everything: the doctor visit, an ultrasound (if needed) and all medications.

You choose the cost you can afford. If the price is a hardship for you, Aria Medical Foundation works with donors to cover part or all of your visit.
33
The cost of your abortion at Aria Medical is $140.

We accept Cash App, major credit cards, debit cards, and also cash.
The fee includes everything: the doctor visit, an ultrasound (if needed) and all medications.

If you cannot afford the fee, please let the front desk know, and we will work out a fee that you can afford.
34
Your appointment is fully funded by our donors, including the cost of the visit, medications, and ultrasound (if you need it). You do not need to pay anything.
35
Will you need help covering the costs of travel to Wichita, Kansas?
Yes
No
36
Do you need an interpreter? If so, select the language.
Please Select
Please Select
Spanish
Hindi
French
Farsi
Other
37
Which language?
38
If you want help with travel costs, text or call Midwest Access Coalition at 847-750-6224. They can help you by booking flights or covering costs of gas, bus fares, lodging, childcare or other expenses.
39
Do any of these apply to you?* This field is required.
I have an allergy to prostaglandins, misoprostol or mifepristone
I have a bleeding disorder (including any condition that causes your blood not to clot normally. Anemia is NOT a bleeding disorder)
In the past, I've had heavy bleeding after miscarriage or medication abortion that required transfusion.
I take blood thinners, including Coumadin (warfarin), apixaban (Eliquis), rivaroxaban (Xarelto) or heparin (Lovenox). (NOT including aspirin)
I take steroid pills, injections or infusions more than 5 days a month for a medical condition. (NOT including steroid sprays, creams, inhalers or testosterone)
I have severe adrenal problems
I have porphyria (very rare condition affecting liver and skin)
I have a severe heart condition (like valve disease requiring surgery, heart failure or cardiomyopathy. Palpitations or PVCs don’t count).
I have had an endometrial ablation (procedure that destroys lining of uterus)
No, I have none of these problems.
40
Drug allergies include:
41
It is not safe to have a medication abortion if you are allergic to the pills. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead.
42
It is not safe to have a medication abortion if you have a bleeding disorder. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at (316) 350-7688 if you have questions.
43
It is not safe to have a medication abortion if you have required a transfusion after an abortion or miscarriage. Please call us to discuss your situation (316-350-7688) before scheduling an appointment. Or go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment.
44
It is not safe to have a medication abortion if you use blood thinners. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at (316) 350-7688 if you have questions.
45
It may not be safe to have a medication abortion if you use steroid medications. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at (316) 350-7688 if you have questions.
46
It may not be safe to have a medication abortion if you have severe adrenal problems. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at (316) 350-7688 if you have questions
47
It is not safe to have a medication abortion if you have porphyria. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at (316) 350-7688 if you have questions
48
It may be not safe to have a medication abortion if you have a severe heart condition. Please call us at (316) 350-7688 to review your medical history before you schedule an appointment. Or you could go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment.
49
It is not safe to have a medication abortion if you have had an endometrial ablation. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment. Call us at 316 350-7688 if you have questions
50
Do you have any allergies to drugs? If yes, list here.
51
Do you have any of the following risk factors for an ectopic pregnancy?* This field is required.
history of ectopic pregnancy
IUD in place at the time you got pregnant
history of tubal ligation (“tubes tied”)
pelvic surgery
history of pelvic inflammatory disease, chlamydia or gonorrhea
no risk factors
52
No risk factors
53
Patient lists the following risk factors for ectopic pregnancy:
history of ectopic pregnancy
IUD in place at the time you got pregnant
history of tubal ligation (“tubes tied”)
pelvic surgery
history of pelvic inflammatory disease, chlamydia or gonorrhea
54
Before you come to Aria, you need to have your IUD removed and have an ultrasound to make sure the pregnancy is in your uterus. Call us if you have questions: (316) 350-7688.
55
Have you had an ultrasound (sonogram) for this pregnancy?* This field is required.
No, I have not had an ultrasound.
Yes, I had an ultrasound and will be 12 weeks or less this coming weekend.
Yes, I had an ultrasound and will be more than 12 weeks this coming weekend.
56
Great. We strongly advise bringing a copy of the ultrasound (sonogram) or the report with you to your appointment, if you have it. It will save time in the clinic.
57
Have you had a positive pregnancy test?* This field is required.
Yes, my pregnancy test is positive.
No, my pregnancy test is negative.
No, I have not done a pregnancy test.
58
You must have a positive pregnancy test before scheduling an abortion appointment. An inexpensive drug store urine test works well. A doctor's office visit is not required to do a pregnancy test.

There are many things other than being pregnant that can make you miss a period. If your pregnancy test is negative, please see a primary care provider to discuss other reasons why you either missed a period or have pregnancy symptoms.
59
When was the first day of your last menstrual period?* This field is required.
We cannot schedule patients who are more than 12 weeks pregnant, based on last menstrual period or ultrasound.
Month
Day
Year
60
It looks like you are less than 6 weeks pregnant.

Abortion pills work best if you are at least 6 weeks — they fail only 2 out 100 times.

If you are 4 weeks, 15 out of 100 medication abortions do not work, and you may need to repeat the pills.

We recommend scheduling your appointment when you will be at least 6 weeks from your last period.
61
We cannot safely schedule you at Aria if you are more than 12 weeks pregnant. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Call (316) 350-7688 if you have questions
62
If one of these apply to you, we STRONGLY recommend you get an ultrasound before you visit.

Breastfeeding

Using pills, patches, rings or shot for birth control

Have irregular periods

Last period was lighter than normal

Any of these a make it harder to know how far along you are. If you are over 12 weeks at the time of your visit, we will not be able to give you pills. You would have to arrange a procedure at another clinic on another day.
63
Today's Date
Date
Month
Day
Year
64
11 week calc
65
It costs Aria $490 to provide you a medication abortion. We only charge you what you can afford, between $5 - $490. Follow-up is virtual -- you do not need to come back to the clinic. Your visit lasts 1-2 hours.
I can pay $490.
I need a discount.
I want to get pills mailed to my home – this is a reliable and lower cost option.
66
PlanCPills.org is a website that lists many options to get pills.

Scroll down to find “clinics that mail pills.” These are on-line medical practices with licensed providers, so you can get support along the way.

Or scroll to “community networks” – these send pills for free, and you can go to the Miscarriage and Abortion Hotline if you want support.
67
How many people live in your household?* This field is required.
Please Select
Please Select
1 (just me)
2
3
4
5
6
7
8
more than 8
68
Do you make more than $16,572 in a year ($1,381 in a month)?* This field is required.
Yes, I make MORE than $16,572 in a year.
No, I make LESS than $16,572 in a year.
69
Do you make more than $22,488 in a year ($1,874 in a month)?* This field is required.
Yes, I make MORE than $22,488 in a year.
No, I make LESS than $22,488 in a year.
70
Do you make more than $28,404 in a year ($2,367 in a month)?* This field is required.
Yes, I make MORE than $28,404 in a year.
No, I make LESS than $28,404 in a year.
71
Do you make more than $34,320 in a year ($2,860 in a month)* This field is required.
Yes, I make MORE than $34,320 in a year.
No, I make LESS than $34,320 in a year.
72
Do you make more than $40,236 in a year ($3,353 in a month)* This field is required.
Yes, I make MORE than $40,236in a year.
No, I make LESS than $40,236 in a year.
73
Do you make more than $46,152 in a year ($3,846 in a month)?* This field is required.
Yes, I make MORE than $46,152 in a year.
No, I make LESS than $46,152 in a year.
74
Do you make more than $52,068 in a year ($4,339 in a month)?* This field is required.
Yes, I make MORE than $52,068 in a year.
No, I make LESS than $52,068 in a year.
75
Do you make more than $57,984 in a year ($4,832 in a month)?* This field is required.
Yes, I make MORE than $57,984 in a year.
No, I make LESS than $57,984 in a year.
76
We can give you a $100 discount, using donor funds. You would pay $390.* This field is required.
I can pay $390.
I can’t pay $390 – I need more financial assistance.
77
We can give you a $210 discount, using donor funds. You would pay $280.* This field is required.
I can pay $280.
I can’t pay $280 – I need more help.
78
We can give you $400 discount, using donor funds. You would pay $90.* This field is required.
I can pay $90.
I can’t pay $90.
79
What amount can you pay for your services? Call us if you have questions about payment: 316-350-7688.* This field is required.
$75
$50
$25
$5
80
Kansas law requires that we ask the following questions. You do not have to answer if you do not want to.
81
In which Kansas county do you live?To skip question, hit next
Please Select
Please Select
Allen
Anderson
Atchison
Barber
Barton
Bourbon
Brown
Butler
Chase
Chautauqua
Cherokee
Cheyenne
Clark
Clay
Cloud
Coffey
Comanche
Cowley
Crawford
Decatur
Dickinson
Doniphan
Douglas
Edwards
Elk
Ellis
Ellsworth
Finney
Ford
Franklin
Geary
Gove
Graham
Grant
Gray
Greeley
Greenwood
Hamilton
Harper
Harvey
Haskell
Hodgeman
Jackson
Jefferson
Jewell
Johnson
Kearny
Kingsman
Kiowa
Labette
Lane
Leavenworth
Lincoln
Linn
Logan
Lyon
Marion
Marshall
McPherson
Meade
Miami
Mitchell
Montgomery
Morris
Morton
Nemaha
Neosho
Ness
Norton
Osage
Osborne
Ottawa
Pawnee
Phillips
Pottawatomie
Pratt
Rawlins
Reno
Republic
Rice
Riley
Rooks
Rush
Russell
Saline
Scott
Sedgwick
Seward
Shawnee
Sheridan
Sherman
Smith
Stafford
Stanton
Stevens
Sumner
Thomas
Trego
Wabaunsee
Wallace
Washington
Wichita
Wilson
Woodson
Wyandotte
82
Kansas law requires that we ask what county you live in.* This field is required. This information is kept confidential.
83
In what province do you live in?To skip question, hit next
84
In which Kansas City/Town do you live?To skip question, hit next
85
Kansas law requires that we ask the following personal questions. If you do not want to answer, hit next. Which city do you live in?
86
Do you live inside the city/town limits?To skip question, hit next
Yes
No
87
Do you consider yourself to be Hispanic or Latina/e?To skip question, hit next
No
Yes
I do not wish to answer.
88
Please specify Hispanic/Latine ethnicity. You may leave blank if you do not wish to answer.To skip question, hit next
Examples include Mexican, Chicano, Cuban, Puerto Rican, etc.
89
How would you describe your race? Select all that apply.To skip question, hit next
White
Black/African American
Native American
Asian/Pacific Islander
Other
I do not wish to answer.
90
Are you married?To skip question, hit next
No, I am not married.
Yes, I am married.
I do not wish to answer.
91
Before this pregnancy, how many other times have you been pregnant?To skip question, hit next
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
You can leave blank if you do not wish to answer.
92
Prior Pregnancy questionsTo skip questions, hit next
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
number of live childbirths
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
number of living children
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
number of natural miscarriages and stillbirths
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
number of abortions
93
How many living children do you have?To skip question, hit next
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
94
How many natural miscarriages have you had?To skip question, hit next
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
95
Before this pregnancy, how many abortions have you had?To skip question, hit next
Please Select
Please Select
None
1
2
3
4
5
6
7
8
9
10 or more
96
What is the highest level of school you have finished?To skip question, hit next
8th Grade or less
9th-12th Grade (no diploma)
High School Graduate/GED
Some College Credit (No Degree)
Associate Degree
Bachelor's Degree
Master's Degree
Doctorate or Professional Degree
97
Your information is kept private. We follow all state and federal privacy laws. Aria Medical sends texts and emails for reminders and follow-up.
98
What is your first name?* This field is required.
as it appears on your ID
99
What is your last name?* This field is required.
as it appears on your ID
100
Name you wished to be called
if you prefer a name other than what's on your ID
101
Phone Number* This field is required.Please provide the best phone number to reach you. We will send appointment confirmations and follow-up surveys to this number. Carrier rates for SMS texts may apply. We will never share your number outside of our system or use it for marketing purposes.
Please enter a valid phone number.
102
Email
example@example.com
103
We're almost done. Please review and put your initials in each box of the consent form, using a mouse or your finger. Then you can schedule your appointment.
104
Aria Medical offers only medication abortion. Medication abortion uses pills to end a pregnancy, very similar to a miscarriage. After your visit, we will send you a follow-up survey by text. Abortions can also be performed by a procedure; if you want a procedure you need to contact another provider.* This field is required.
105
You understand that Aria will only give abortion pills if your pregnancy is less than 12 weeks. Doing an ultrasound before your visit is the best way to know how far along you are. If you can’t get an ultrasound in advance, Aria will do an abdominal ultrasound during your visit. This is to confirm the pregnancy is in your uterus and to know the number of weeks. We do a vaginal ultrasound only if we cannot see the pregnancy on abdominal ultrasound. If you are over 12 weeks, Aria will help you find a clinic to do a procedure on another day, possibly in another state, if Kansas clinics are booked up.* This field is required.
106
The Aria ultrasound will not diagnose conditions other than pregnancy and is unlikely to show an ectopic pregnancy, if it is there. If we cannot see a pregnancy in the uterus, you can still get the abortion pills during your visit and we will review warning signs of an ectopic pregnancy. You may need to get follow-up labs or a follow-up ultrasound to confirm the abortion worked. If you have an ectopic pregnancy, we will help you to get treatment. Untreated ectopic pregnancy is life-threatening. Treatment of ectopic pregnancy is legal in all 50 states.* This field is required.
107
Abortion pills are extremely safe, even safer than Tylenol. Rare but serious risks of medication abortion include (1) undiagnosed ectopic pregnancy with rupture, causing life-threatening bleeding without medical care, (2) hemorrhage or retained tissue, requiring a procedure for treatment, (3) infection, or (4) death. Death in childbirth is 10-20 times more likely than death from abortion.* This field is required.
108
There is a very small chance that the medications do not work and you stay pregnant. If this happens, Aria will help you do a second medication abortion or find a clinic to have a procedure. Aria does not do procedures – you would need to have the procedure in another clinic, potentially in another state because of high demand in Kansas.* This field is required.
109
I agree to receive SMS texts for appointment reminders and follow-up care. I understand my cell phone carrier may impose charges for SMS texts. I will reply to the follow-up surveys sent via text after my appointment. The survey is VERY important. We want to make sure the pills worked. I may opt out of texts at my own risk by replying "STOP" by text.* This field is required.
110
Your visit at Aria Medical Clinic usually lasts 1-2 hours. You will meet with a warm and welcoming staff to answer all of your questions. You will receive an abdominal ultrasound if you haven't had one yet. If you have already had a sonogram, please bring the image or the report. You will see a doctor via live video.

We make sure you understand the process and all your questions are answered before you leave.

Click “Submit” below to schedule your appointment.
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Cost language
112
Cost
113
Translation services
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Date and Time
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