• Filling out this form does not mean that you have an appointment scheduled. A member of our Care Clinic Colorado staff will contact you to complete the scheduling process.

    Please fill in the information below, and our staff will contact you within 2 business days to schedule your appointment, review financial assistance options, and answer any questions you may have. For a faster response, please call us at (719) 884-4070 or text us at (719) 888-7118. Our phones are open 24 hours a day, Monday through Saturday.

    Care Clinic Colorado provides in-clinic visits for abortion pills and abortion procedures up to 26 weeks and 6 days of pregnancy.

    Please submit only one request form per patient. Submitting more than one form may result in delays in processing your request.

  • Phone Number*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Appointment Time
  • Preferred Contact Time

  • Medical History

  • Do you have a history of:
  • History of Drug/Alcohol Abuse:*
  • Current Smoker?*
  • Do you have any known allergies?*
  • Are there any complications or problems associated with this pregnancy:*

  • Obstetric and Menstrual History

  • Do you know the date of your last menstrual period?*
  • When was your last menstrual period?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you have an ultrasound(U/S) to confirm this pregnancy?*
  • When was the U/S completed?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last delivery
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was the due date?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you ever have an ectopic or molar pregnancy?*
  • Do you have an IUD in place?*

  • Financial Assistance Screening

  • Are you currently receiving public assistance?
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  • Text Messaging and Opt-Out Policy
    By providing your phone number and opting in to receive text messages from our company, you consent to receive SMS and MMS messages regarding your account, services, promotional offers, or other relevant information. Message frequency may vary.

    Opt-Out:
    You can opt out of receiving text messages from us at any time. To stop receiving messages, simply reply "STOP" to any text message you receive from us. After opting out, you will no longer receive text messages unless you re-enroll by contacting us or providing express consent again.

    Message and Data Rates:
    Standard message and data rates may apply to any text messages sent or received, depending on your mobile carrier's plan.

    Privacy and Patient Information:
    We are committed to protecting your privacy and the confidentiality of your patient information. By opting in, you agree to the use of your information solely for the purpose of communication related to your healthcare and services.

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