Scotsdale Women's Center - Telehealth Eligibility Screening

First Name:*
Last Name:*
Do you have a Michigan mailing address?*

YesNo
Have you had a positive pregnancy test?*

YesNo
How old are you?
First day of your last period?*

MonthDayYear
Date
How confident are you about the date of your last period?*

PositivePretty ConfidentNot So Sure
Were your last three periods regular (every 21-32 days)?*

YesNo
Email*
example@example.com
Do you currently have an IUD in place?*

YesNo
Do you have a history of anemia?*

YesNo
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.
Please prove that you are human.*
Date

MonthDayYear
Date
Estimated Days Pregnant
Should be Empty: