Her Choice- Abortion Pill Online Questionaire Updated Form

Do you agree to our telehealth consent and terms and conditions?*

YesNo

What is your age?*

Do you know your estimated gestational age from an ultrasound during this pregnancy?*

YesNo

Current Date (For Calculation)

Date

Input your ultrasound gestational age (in weeks)*

Enter the first day of your last period (assuming you have regular periods)

Date

MP Calculation

Do you have any reason to suspect you may have conceived more than 8 weeks ago?*

YesNo

Do you or your medical provider have any reason to suspect you might have an ectopic or tubal pregnancy?

YesNo

Do you have an intrauterine device (IUD) currently in your uterus?*

YesNo

Have you taken aspirin, Coumadin, Heparin, Eliquis, Plavix or any other blood thinners in the last 7 Days?*

YesNo

Are you taking any oral or injectable steroids such as prednisone or hydrocortisone on a long term basis (more than 2 months), or do you have a history of chronic adrenal failure?*

YesNo

Are you allergic to Mifeprex (mifepristone) or Misoprostol (Cytotec)?*

YesNo

Do you have a medical diagnosis of a hemorrhagic (bleeding) disorder, or porphyria?*

YesNo

Telephone communications are not always completely secure or encrypted, and even though we take all steps to ensure privacy, it cannot be guaranteed. Do you consent to telephone communication to discuss your care prior to receiving the medications?*

YesNo

Text communications are not always completely secure or encrypted, and your privacy cannot be guaranteed. Do you consent to text communication?*

YesNo

We are sorry, but based on the information you have provided, you do not qualify for the abortion pill to be mailed to you, and will need to be seen in person. You may contact us directly by phone at 714-966-9094 to schedule an in person consultation for abortion services.

Thank you.
Based on your preliminary answers, it is very likely that you qualify to receive the abortion pill by mail, although we cannot guarantee that at this stage. Our Ob/ Gyn physician will review your history within 24-48 hours of receipt Monday-Friday 9am-4pm PST, and will call you shortly after to discuss your care and confirm whether or not you qualify to receive the abortion pill by mail. Please make sure you provide the best phone number for our physician to contact you.
While it is not always mandatory to have an ultrasound performed prior to taking this pill, it is preferred and recommended. If you are not sure about your conception date, we highly recommend an ultrasound prior to taking the abortion pill. Our physician will discuss this with you further.

The total fee for consultation, abortion pills, and standard ground shipping is $399. $35 due now, and a remaining balance of $364.

You will be charged an initial consultation fee of $35 for our physician to review your medical history. This fee is non-refundable, whether or not you qualify or choose to take the pill. The $35 fee will be applied to your total if you qualify and choose to have the pills mailed to you. After the phone consultation, if you still qualify and choose to have the pills mailed to you, you will be charged the balance of $364, and the medications will be mailed to you within 24 hours Monday - Friday. The fee includes standard ground shipping, but expedited shipping is also available for an additional cost.An incorrect address entry will result in significant delays and added costs to receiving your medication, potentially resulting in you no longer qualifying for the abortion medication due to pregnancy age limits.
Refunds will not be issued for incorrect address entry, or for any other reason once the order has been processed.

Please note that once your order is processed, you will not qualify for a refund. Mailed medications are not refundable or returnable.
Please do not submit multiple questionnaires or orders. Duplicate orders and charges will not be refunded, since each submission will have to be reviewed.

If you need to make any changes prior to your order processing, please contact us at support@herchoiceclinic.com

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Our health provider/s will be calling you at this number to discuss your care.

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

What state do you live in?*

We are sorry, but we do not ship to any address outside of California therefore you do not qualify for the abortion pill to be mailed to you, and will need to be seen in person. You may contact us directly by phone at 714-966-9094 to schedule an in person consultation for abortion services.

Danco Consent

Patient Agreement Form
Mifepristone tablets, 200 mg
Healthcare providers: Counsel the patient on the risks of mifepristone. Both you and the patient must sign this form.

Patient Agreement:

I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my provider’s advice about when to take each drug and what to do in an emergency.
I understand:
• I will take mifepristone on Day 1.
• My provider will either give me or prescribe for me the misoprostol tablets which I will take 24 to 48 hours after I take mifepristone.
My healthcare provider has talked to me about the risks including:
• Heavy bleeding
• Infection
• Ectopic pregnancy (a pregnancy outside the womb)
I will contact the clinic/office right away if in the days after treatment I have:
• A fever of 100.4°F or higher that lasts more than four hours
• Severe stomach area (abdominal) pain
• Heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)
• Stomach pain or discomfort, or I am “feeling sick”, including weakness, nausea, vomiting, or diarrhea, more than 24 hours after taking misoprostol
My healthcare provider has told me that these symptoms could require emergency care. If I cannot reach the clinic or office right away my provider has told me who to call and what to do.
I should follow up with my provider 7 to 14 days after I take mifepristone to be sure my pregnancy has ended and I am well.
I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use the treatment. If my pregnancy continues after treatment with mifepristone and misoprostol, I will talk with my provider about a surgical procedure to end my pregnancy.
If I need a surgical procedure because the medicines did not stop my pregnancy or to stop heavy bleeding, my healthcare provider has told me whether they will do the procedure or refer me to another healthcare provider who will.
I have the MEDICATION GUIDE for mifepristone. I will take it with me if I visit an emergency room or a healthcare provider who did not give me mifepristone so that they will understand that I am having a medical abortion with mifepristone.
My care will be discussed with my healthcare provider, and I will have the opportunity to have my provider answer any of my questions prior to taking the abortion pill.

Print Name*

First NameLast Name

Signature for Danco Consent

Current Date Signed

Date

Signature

Our health provider/s will be calling you at this number to discuss your care.

Abortion Pill*

Consultation Fee

$35.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Approval Signature

Patient acknowledgement of the above: