Scotsdale Women's Center - Telehealth Form

Name*

First NameLast Name
Pronouns: *

she/herthey/themhe/him
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Have you been a patient with us in the last three years? *

YesNo
If it is necessary to contact you, do we have your permission to (check all that apply):*

Call you?Leave a voicemail?Text you?Email you?
We are sorry, but you do not qualify for abortion pills by mail. We have other options - call us at (313) 538-2020 to find the right method for you.

Pregnancy History
How many live births have you had?*
How many miscarriages have you had?*
How many abortions have you had?*
Have you ever had an ectopic pregnancy (a pregnancy in your tubes)?*

YesNo
Did you ever experience bleeding complications with your previous pregnancies? *

YesNoDoes not apply to me

Ectopic Pregnancy

Abortion pills will not work to end ectopic pregnancies. Please read this information about ectopic pregnancy.

Ectopic Pregnancy Fact Sheet
Do you feel confident in your decision to end your pregnancy?*

YesNo
Is anyone forcing you to end your pregnancy? *

YesNo

My Products

Medical Abortion by Mail

$1.00

Total

$0.00