• Are you 11 weeks pregnant or less by your last menstrual period? *
  • Are you able to access the internet with a phone, tablet or computer with video connection? *
  • Are you a resident of New York State?*

  • Please call 718-786-5000 or book online here to schedule an on-site appointment at CHOICES.

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • Do you currently have an intrauterine device (IUD) in place?*
  • Have you ever had an allergic reaction to mifepristone or misoprostol?*
  • Have you been diagnosed with chronic adrenal failure?*
  • Are you currently taking long-term systemic steroid medications (such as oral or injected steroids)? (This does not include steroid inhalers.)*
  • Have you been diagnosed with a bleeding disorder, such as hemophilia or Von Willebrand disease?*
  • Are you currently taking blood-thinning medications such as heparin, Lovenox, or Coumadin?*
  • Have you had severe anemia in the past, such as a hemoglobin level below 9 or a blood transfusion within the last year?*
  • Have you ever had an ectopic pregnancy (a pregnancy outside of the uterus, treated withan injection or surgery)?*
  • Have you had vaginal bleeding since your last menstrual period?*
  • Are you experiencing pain in your lower abdomen or pelvic area, or have you been told you have an adnexal mass?*
  • Have you ever had surgery on your fallopian tubes (such as tubal ligation or sterilization)?*
  • Have you ever been hospitalized or treated for a pelvic infection, such as pelvic inflammatory disease (PID)?*
  • When was the first day of your last menstrual cycle? *
     - -

  • To calculate, use the pregnancy calculator here.

  • When are you looking to be seen? *
     - -
  • Are you looking to use insurance or self-pay for your visit?*
  • Should be Empty: