Plan B Request Form

Plan B Request Form

Please fill out this form to request a Plan B from H*yas for Choice. Anyone taking Plan B MUST fill out the form! You can use someone else's number if they're picking it up for you, but you must sign your name and complete this form for legal reasons. Members of the board will immediately be notified and will attempt to fulfill your order as soon as possible. A board member will contact you via TEXT to schedule a quick pick-up of the Plan B. IF for some reason, the order is not fulfilled in time, please email board@hyasforchoice.org
DELIVERIES PAUSED FROM NOVEMBER 21 UNTIL DECEMBER 1. FOR ADDITIONAL RESOURCES, FEEL FREE TO REFERENCE OUR WEBSITE!
Name (First Name Only is Okay)*
*Only for contact purposes. We do not make assumptions about who the request is for. This form is confidential. Person who will be taking the Plan B
Phone*
Person who will be picking up the Plan B
Campus*

Main CampusCALL/Capital Campus
Emergency contraceptive (Plan B) must be used within 72 hours of unprotected sex. Side effects include: nausea, dizziness, changes in the menstrual cycle, and headaches. Those who vomit within two hours of taking Plan B may require a second dose. In these cases, please consult a healthcare professional. *

I understand
H*yas for Choice is so happy we can provide you with EC! Please carefully read the directions included on the emergency contraception pill package. H*yas for Choice members are Georgetown students, not medical professionals, so we cannot provide any medical advice. Talk to a doctor if you have any questions or concerns. By signing below and accepting the emergency contraception pill package, you agree to release and hold harmless H*yas for Choice and each of its members from any and all claims or suits (including suits based on negligence and personal injury) that may arise from your use of the emergency contraception pill package.
By signing below and accepting the emergency contraception pill package, you agree to release and hold harmless H*yas for Choice and each of its members from any and all claims or suits (including suits based on negligence and personal injury) that may arise from your use of the emergency contraception pill package

First NameLast Name
By checking this box, I acknowledge that my digital signature above is the legally binding equivalent of my handwritten signature on paper.

I agree
By checking this box, I consent to providing my email in the case that H*yas For Choice contacts me regarding Emergency Contraception. H*yas For Choice will not use your email outside of this context (e.g. unsolicited listerv).

I agree
Though emergency contraception is effective in emergency settings, it should not be used in lieu of other contraceptive methods. It is not a reliable form of birth control. We are happy to provide you the service as often as you need it and will not turn anyone away, but if you find yourself needing to use emergency contraception more than 2-3 times a year please consider meeting with your doctor about a more effective form of birth control, whether it be hormonal or by using barrier methods.
We would be so grateful for any donations to support our Plan B services! Your generosity helps us continue offering Plan B and other essential reproductive health services to students on campus. If you're able to, please consider donating $15 (or whatever amount works for you) via Venmo or PayPal @hyasforchoice. Every little bit makes a big difference, and we truly appreciate your support!
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