FemCap

1
Please select Yes or No if you have experienced any of the following:* This field is required.1. Do you have an allergy to Silicone? 2. Do you have any Cervical or Vaginal Abnormalities? 3. Have you had any recent Cervical Surgery? 4. Do you have a history of Toxic Shock Syndrome (TSS)? 5. Are you at High Risk of HIV/STI(s)? 6. Do you have a history of Frequent Vaginal Infections? 7. Have you had any Abnormal Pap Smear Results recently? 8. Do you have a spermicide allergy? 9. Are you within 8-10 weeks post-childbirth or post abortion?
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
4
Full Name* This field is required.
First Name
Last Name
5
Phone Number* This field is required.
Phone number
6
E-mail* This field is required.
7
Birth Date* This field is required.
Month
Day
Year
8
Billing Address* This field is required..
Street Address
Street Address Line 2
City
State
Postal / Zip Code
United States
Please Select
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Algeria
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Botswana
Brazil
Brunei
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Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
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Chad
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China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
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Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
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The Gambia
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Ghana
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Greece
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Kiribati
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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
9
Shipping Address(If different from billing address) Please fill out the shipping address below you want the FemCap 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
10
Please enter your preferred language below. (optional)
11
Do you have insurance?* This field is required.
YESNO
12
If using insurance, upload a photo of your insurance card (front/back)* This field is required.
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Select files to upload
Max. file size: 10.6MB
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Please upload a photo of your ID (front/back)* This field is required.
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Select files to upload
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. Important Notice for Patients with Non-Medicaid Insurance In the past, if you had insurance, My Virtual Physician usually collected very little money from you up front. Most of the time, your insurance company paid for your visit, and you only had to pay a small amount, if anything, later. Now, insurance companies are making patients pay a bigger share of their medical bills. This means you might have to pay more out of your own pocket, even after your visit. Because of these changes, we are starting a new policy for patients who use insurance (except Medicaid): 1. Deposit Needed: You will need to pay a deposit of $74.98 when you schedule your visit. 2. We Still Bill Your Insurance: We will still send the bill to your insurance company, so the amount can count toward your deductible or out-of-pocket costs. 3. Get Your Explanation of Payment (EOP) Statement: After your visit, please ask your insurance company for an Explanation of Payment (EOP) statement. - We need this statement to see how much your insurance paid us. - This helps us figure out if you still owe anything, or if we need to refund part of your deposit. Thank you for understanding and helping us keep things clear and fair. If you have any questions about this policy or your bill, please contact our office by Text: 725 228 8277 Phone: 888 224 0804 or Email:Billing@myvirtualphysician.com Self Pay Patients or Out Of Network Insurance patients will pay the fee of $65.00 If you have questions in regards to your Insurance Network Participation status 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 FemCap prescription will by default be sent to the American Mail Order Pharmacy, please contact American Mail Order Pharmacy at (888)772-3811 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 FemCap or other methods of contraception, please contact My Virtual Physician at (888) 224-0804.
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