Nurse Navigator Contact Request

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To request free birth control pills without receiving a callback from a staff member, you can visit this link to fill out an intake form. If you would like to speak to a staff member, please continue filling out this form.

To schedule an appointment, please call our appointment line anytime Monday-Thursday from 10 am - 4 pm at 423-265-7837.

Our service area includes the following 18 counties:

If you do not live or go to school in our 18-county service area, you can reach out to your local health department for additional information and resources.
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Date* This field is required.
Date
Month
Day
Year
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Please enter your date of birth.* This field is required.
Date
Month
Day
Year
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Age
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Per state law, since you are under the age of 18, you will need to have a parent or guardian present when a Nurse Navigator contacts you.

Since we must verify a parent or guardian is present, we cannot provide information via text message or email.
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County of Residence* This field is required.
Bledsoe, TN
Rhea, TN
Bradley, TN
Sequatchie, TN
Franklin, TN
Catoosa, GA
Grundy, TN
Dade, GA
Hamilton, TN
Murray, GA
Marion, TN
Walker, GA
McMinn, TN
Whitfield, GA
Meigs, TN
DeKalb, AL
Polk, TN
Jackson, AL
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Full Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Preferred Contact Method* This field is required.
Phone
Text
Email
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Preferred Contact Method
Phone
Text
Email
Phone, Text
Phone, Email
Text, Email
Phone, Text, Email
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Please note - Appointments can ONLY be scheduled via phone. At this time, we are unable to schedule appointments via text or email.
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Since you are under 18, we can only contact you via phone with a parent or guardian present. Choose a date and time to schedule an appointment and speak with our Nurse Navigator to learn more about birth control and reproductive health. Appointments CANNOT be scheduled via text or email. Please be sure to click submit in the bottom right corner after scheduling your appointment. * This field is required.*The information provided is not a substitute for professional medical evaluation, diagnosis, or treatment.
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Would you like to be signed up to receive our quarterly newsletter?* This field is required.
Yes, subscribe me to the newsletter.
No.
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Choose a date and time to schedule an appointment and speak with our Nurse Navigator to learn more about birth control and reproductive health. Appointments CANNOT be scheduled via text or email. Please be sure to click submit in the bottom right corner after scheduling your appointment. * This field is required.*The information provided is not a substitute for professional medical evaluation, diagnosis, or treatment.
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