Aria OH Online Intake

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IntakeThis survey takes 5-10 minutes to complete.
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Are you the person who will get the abortion?* This field is required.
Yes
No, I am scheduling for someone else
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Patients should schedule their OWN appointments. You can share our website with the patient and help them schedule, but do not submit medical information for someone other than yourself. This is to ensure safety and quality care.
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Date of Birth* This field is required.
as listed on your photo ID
Month
Day
Year
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Qualifying age
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Ohio laws require a one parent to sign a consent form at your appointment.

If you live in Ohio, and a parent can bring you: make sure you each have IDs, and if you have different last names, bring proof of parenthood/guardianship (like a birth certificate, guardianship papers). Call us if you aren’t sure what you need. (740) 448-6571‬

Don’t want to tell your parents? Or live outside of Ohio? Call us — we can help! (740) 448-6571‬
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Have you had a positive pregnancy test?* This field is required.
Yes, my pregnancy test is positive.
No, my pregnancy test is negative.
No, I have not done a pregnancy test.
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You must have a positive pregnancy test before scheduling an abortion appointment. An inexpensive drug store urine test works well. You can also come by JustChoice.org for a free pregnancy test.

There are many things other than being pregnant that can make you miss a period. If your pregnancy test is negative, please see a primary care provider to discuss other reasons why you either missed a period or have pregnancy symptoms.
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Unique ID
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Ban state?
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Financial need?
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Fund
Please Select
Please Select
none
TAF
NAF
NAF_plus_Sliding_Scale
NAF_plus_KAF
MOAF_fully_funded
MOAF_Sliding_Scale
AASN_fully_funded
AASN_Sliding_Scale
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Will you need help covering the costs of travel?
Yes
No
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If you want help with travel costs, text or call the Ohio Women’s Alliance. They can help you by booking flights or covering costs of gas, airfare, bus fares, lodging, childcare or other expenses. If they are closed, please reach out to us in the secure app (after you book your appointment) or call us at ‭(614) 551-4642 and we can help.
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Do you need an interpreter? If so, select the language.
Please Select
Please Select
Spanish
Hindi
French
Farsi
Other
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Which language?
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Do any of these apply to you?* This field is required.
I have an IUD in place right now.
I have an allergy to prostaglandins, misoprostol or mifepristone
I have a bleeding disorder (including any condition that causes your blood not to clot normally. Anemia is NOT a bleeding disorder)
In the past, I've had heavy bleeding after miscarriage or medication abortion that required transfusion.
I take blood thinners, including Coumadin (warfarin), apixaban (Eliquis), rivaroxaban (Xarelto) or heparin (Lovenox). (NOT including aspirin)
I take steroid pills, injections or infusions more than 5 days a month for a medical condition. (NOT including steroid sprays, creams, inhalers or testosterone)
I have severe adrenal problems
I have porphyria (very rare condition affecting liver and skin)
I have a severe heart condition (like valve disease requiring surgery, heart failure or cardiomyopathy. Palpitations or PVCs don’t count).
I have had an endometrial ablation (procedure that destroys lining of uterus)
I have symptoms like dizziness or severe fatigue from anemia.
No, I have none of these problems.
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Drug allergies include:
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The IUD must be removed BEFORE your appointment.

Please make an appointment with a provider near you to remove it (try bedsider.org or call us and we can help: (614) 551-4642).

You can remove your own IUD — click here for instructions.

If you got pregnant with an IUD in place, we recommend an ultrasound to find out if you have an ectopic pregnancy. Abortion pills do not treat ectopic pregnancies. Ectopics are treatable by OBGYNs in all 50 states.

If you cannot remove your IUD and you still want an appointment, please call us first (614) 551-4642 and we can help.

Or call the MA Hotline at 1-833-246-2632 to learn about other options.
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It may not be safe for you to use mifepristone, one of the abortion pills.

You have two other options:

Get an abortion procedure. You can go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your medical history when you make an appointment.

You can still use misoprostol. Misoprostol is about 85% effective, when used without mifepristone. We can offer you a misoprostol-only abortion.

Call us at (740) 448-6571‬ if you have questions
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It may not be safe to have a medication abortion if you have a bleeding disorder.
We recommend a procedure — please go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your condition when you make an appointment.
Call us at (740) 448-6571‬ if you have questions.
Or contact the MA Hotline at 1-833-246-2632.
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It may not be safe to have a medication abortion if you needed a transfusion after an abortion or miscarriage. Please call us to discuss your situation (740-448-6571‬) before scheduling an appointment.
Or go to INeedAnA.com to schedule a procedure. Make sure to tell the clinic about your condition when you make an appointment.
Or contact the MA Hotline at 1-833-246-2632 to explore other options for medication abortion.
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It may not be safe to have a medication abortion if you take blood thinners.
We recommend a procedure — please go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your condition when you make an appointment.
Call us at (740) 448-6571‬ if you have questions.
Or contact the MA Hotline at 1-833-246-2632.
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It may not be safe for you to use mifepristone, one of the abortion pills.

You have two other options:

Get an abortion procedure. You can go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your medical history when you make an appointment.

You can still use misoprostol. Misoprostol is about 85% effective, when used without mifepristone. We can offer you a misoprostol-only abortion.

Call us at (740) 448-6571‬ if you have questions
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It may not be safe for you to use mifepristone, one of the abortion pills.

You have two other options:

Get an abortion procedure. You can go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your medical history when you make an appointment.

You can still use misoprostol. Misoprostol is about 85% effective, when used without mifepristone. We can offer you a misoprostol-only abortion.

Call us at (740) 448-6571‬ if you have questions
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It may not be safe for you to use mifepristone, one of the abortion pills.

You have two other options:

Get an abortion procedure. You can go to INeedAnA.com to find a clinic that works for you. Make sure to tell the clinic about your medical history when you make an appointment.

You can still use misoprostol. Misoprostol is about 85% effective, when used without mifepristone. We can offer you a misoprostol-only abortion.

Call us at (740) 448-6571‬ if you have questions
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It may be not safe to have a medication abortion if you have a severe heart condition. Please call us at (740) 448-6571‬ to review your medical history before you schedule an appointment. Or you could go to abortionfinder.org or ineedana.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment.
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It may not be safe to have a medication abortion if you have had an endometrial ablation, a procedure that destroys the lining of your uterus.

Call us if you have questions about your particular situation: (740) 448-6571‬. Or you can go to INeedAnA.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment, as they may require you to do your procedure in an operating room instead of an outpatient clinic.
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If you have severe anemia, and you have symptoms from anemia like dizziness or fatigue, it may be safer for you to get a procedure abortion. Call us if you have questions about your particular situation: (740) 448-6571‬. Or you can go to INeedAnA.com to schedule a procedure instead. Make sure to tell the clinic about your condition when you make an appointment.
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Do you have any allergies to drugs? If yes, list here.
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Are any of these true for you?* This field is required.
I have had an ectopic pregnancy before
I have had a tubal ligation (tubes tied)
I had an IUD in place at the time I got pregnant
None of these are true for me
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You are at higher risk for an ectopic pregnancy.

An ectopic pregnancy is an abnormal pregnancy growing outside the uterus, usually in the tubes.

If you are traveling a long distance for your appointment, we strongly recommend getting an ultrasound before your visit.

Ectopic pregnancies can be treated in all 50 states. Abortion pills do not work to treat ectopic pregnancies. Please call us if you have any questions: (740) 448-6571‬.
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No risk factors
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Patient lists the following risk factors for ectopic pregnancy:
I have an IUD in place right now.
I have an allergy to prostaglandins, misoprostol or mifepristone
I have a bleeding disorder (including any condition that causes your blood not to clot normally. Anemia is NOT a bleeding disorder)
In the past, I've had heavy bleeding after miscarriage or medication abortion that required transfusion.
I take blood thinners, including Coumadin (warfarin), apixaban (Eliquis), rivaroxaban (Xarelto) or heparin (Lovenox). (NOT including aspirin)
I take steroid pills, injections or infusions more than 5 days a month for a medical condition. (NOT including steroid sprays, creams, inhalers or testosterone)
I have severe adrenal problems
I have porphyria (very rare condition affecting liver and skin)
I have a severe heart condition (like valve disease requiring surgery, heart failure or cardiomyopathy. Palpitations or PVCs don’t count).
I have had an endometrial ablation (procedure that destroys lining of uterus)
I have symptoms like dizziness or severe fatigue from anemia.
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Before you come, you need to have your IUD removed and have an ultrasound to make sure the pregnancy is in your uterus. Call us if you have questions: (740) 448-6571‬.
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Have you had an ultrasound (sonogram) for this pregnancy?* This field is required.
No, I have not had an ultrasound.
Yes, I had an ultrasound and will be 12 weeks or less this coming weekend.
Yes, I had an ultrasound and will be more than 12 weeks this coming weekend.
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Great. We strongly advise bringing a copy of the ultrasound (sonogram) or the report with you to your appointment, if you have it. It will save time in the clinic.
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When was the first day of your last menstrual period?* This field is required.
We cannot schedule patients who are more than 12 weeks pregnant, based on last menstrual period or ultrasound.
Month
Day
Year
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It looks like you are less than 6 weeks pregnant.

Abortion pills work best if you are at least 6 weeks — they fail only 2 out 100 times.

If you are 4 weeks, 15 out of 100 medication abortions do not work, and you may need to repeat the pills.

We recommend scheduling your appointment when you will be at least 6 weeks from your last period.
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We cannot safely schedule you for a medication abortion if you are more than 12 weeks pregnant. Please go to abortionfinder.org or ineedana.com to schedule a procedure instead. Call (740) 448-6571‬ if you have questions
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If one of these apply to you, we STRONGLY recommend you get an ultrasound before your visit, if you are driving a long way to the appointment.

Breastfeeding

Using pills, patches, rings or shot for birth control

Have irregular periods

Last period was lighter than normal

Any of these make it harder to know how far along you are. If you are over 12 weeks at the time of your visit, we will not be able to give you pills. You would have to arrange a procedure at another clinic on another day.
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Today's Date
Date
Month
Day
Year
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11 week calc
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It costs us $490 to provide you a medication abortion. We only charge you what you can afford, between $50 - $490. Follow-up is virtual -- you do not need to come back to the clinic. Your visit lasts 1-2 hours.
I can pay $490.
I need a discount.
I want to get pills mailed to my home – this is a reliable and lower cost option.
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Mayday.Health is a website listing reliable clinics that send pills by mail. These are the same pills we offer at our clinic.

Cost for mail-order pills is typically $5-150 or more.

If you want support or advice about getting pills by mail, contact the Miscarriage and Abortion Hotline 1-833-246-2632.
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How many people live in your household?* This field is required.
Please Select
Please Select
1 (just me)
2
3
4
5
6
7
8
more than 8
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Do you make more than $16,572 in a year ($1,381 in a month)?* This field is required.
Yes, I make MORE than $16,572 in a year.
No, I make LESS than $16,572 in a year.
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Do you make more than $22,488 in a year ($1,874 in a month)?* This field is required.
Yes, I make MORE than $22,488 in a year.
No, I make LESS than $22,488 in a year.
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Do you make more than $28,404 in a year ($2,367 in a month)?* This field is required.
Yes, I make MORE than $28,404 in a year.
No, I make LESS than $28,404 in a year.
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Do you make more than $34,320 in a year ($2,860 in a month)* This field is required.
Yes, I make MORE than $34,320 in a year.
No, I make LESS than $34,320 in a year.
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Do you make more than $40,236 in a year ($3,353 in a month)* This field is required.
Yes, I make MORE than $40,236 in a year.
No, I make LESS than $40,236 in a year.
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Do you make more than $46,152 in a year ($3,846 in a month)?* This field is required.
Yes, I make MORE than $46,152 in a year.
No, I make LESS than $46,152 in a year.
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Do you make more than $52,068 in a year ($4,339 in a month)?* This field is required.
Yes, I make MORE than $52,068 in a year.
No, I make LESS than $52,068 in a year.
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Do you make more than $57,984 in a year ($4,832 in a month)?* This field is required.
Yes, I make MORE than $57,984 in a year.
No, I make LESS than $57,984 in a year.
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We can give you a $100 discount, using donor funds. You would pay $390.* This field is required.
I can pay $390.
I can’t pay $390 – I need more financial assistance.
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We can give you a $210 discount, using donor funds. You would pay $280.* This field is required.
I can pay $280.
I can’t pay $280 – I need more help.
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We can give you a $310 discount, using donor funds. You would pay $180.* This field is required.
I can pay $180.
I can’t pay $180 - I need more help.
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We can give you $400 discount, using donor funds. You would pay $90.* This field is required.
I can pay $90.
I can’t pay $90 - I need more help.
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We can give you $415 discount, using donor funds. You would pay $75.* This field is required.
I can pay $75.
I can’t pay $75 - I need more help.
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We can give you $440 discount, using donor funds. Your appointment cost is $50. Please contact us if $50 presents difficulty for you, or if already have a voucher covering your services: (740) 448-6571‬* This field is required.
I can pay $50.
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Your information is kept private. We follow all state and federal privacy laws. We may use text, email or secure app for reminders and follow-up.
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What is your first name?* This field is required.
as it appears on your ID
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What is your last name?* This field is required.
as it appears on your ID
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We're almost done. Please review and put your initials in each box of the consent form, using a mouse or your finger. Then you can schedule your appointment.
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We only offer medication abortion, using pills to end a pregnancy, very similar to miscarriage. After your visit, we will send you a follow-up survey. If you want an abortion procedure, you will need to contact another provider.* This field is required.
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We only offer abortion pills if your pregnancy is less than 12 weeks. We do an abdominal ultrasound to confirm the pregnancy is in the uterus and to know how far along you are. We offer a vaginal ultrasound if we cannot see the pregnancy on abdominal ultrasound. If you are over 12 weeks, we help you find a clinic to do the procedure on another day. If you think you might be over 12 weeks, and you are traveling a long distance, we recommend getting an ultrasound before your visit.* This field is required.
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Our ultrasound will not diagnose conditions other than pregnancy and is unlikely to show an ectopic pregnancy, if it is there. If we cannot see a pregnancy in the uterus, you can still get the abortion pills during your visit and we will review warning signs of an ectopic pregnancy. You may need to get follow-up labs or a follow-up ultrasound to confirm the abortion worked. If you have an ectopic pregnancy, we will help you to get treatment. Untreated ectopic pregnancy is life-threatening. Treatment of ectopic pregnancy is legal in all 50 states.* This field is required.
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Abortion pills are extremely safe, even safer than Tylenol. Rare but serious risks of medication abortion include (1) undiagnosed ectopic pregnancy with rupture, causing life-threatening bleeding without medical care, (2) hemorrhage or retained tissue, requiring a procedure for treatment, (3) infection, or (4) death. Death in childbirth is 10-20 times more likely than death from abortion.* This field is required.
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There is a very small chance that the medications do not work and you stay pregnant. If this happens, we will help you do a second medication abortion or find a clinic to have a procedure. We do not do procedures – you would need to have the procedure in another clinic.* This field is required.
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I agree to receive SMS texts for appointment reminders and follow-up care. I understand my cell phone carrier may impose charges for SMS texts. I will reply to the follow-up surveys sent via text after my appointment. The survey is VERY important. We want to make sure the pills worked. I may opt out of texts at my own risk by replying "STOP" by text.* This field is required.
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Before hitting submit and scheduling your appointment, please let us know how you found us.
Recommendation from friend or family
Google search
INeedAnA.com
PlanCPills.org
AbortionFinder.org
Abortion Fund of Ohio
Ohio Women’s Alliance
JustChoice
Referred/Other
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Referred/OtherPlease specify:
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Your visit will be at the JustCenter at JustChoice -- you will receive the address by email after you confirm your appointment. You will meet with a warm and welcoming staff to answer all of your questions. You will receive an abdominal ultrasound if you have not had one yet. If you already had an ultrasound, please bring the image or report.

Expect to be with us 1-2 hours. We make sure you understand the process and all your questions are answered before you leave.
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In Columbus, we have Thursday appointments. In Cincinnati, we have appointments Wednesday - Friday. Which do you prefer?* This field is required.
show me only Columbus appointments
show me only Cincinnati appointments
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Last thing before you schedule your appointment! Ohio law requires us to anonymously report certain details about our patients. We do not share your name.

If you do not want to answer any of these questions, check "Prefer not to answer"
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What is your zip code?* This field is required.
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What county do you live in? (not country — please do not write United States)* This field is required.
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What state do you live in?* This field is required.
Please Select
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Alabama
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California
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District of Columbia
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KANSAS
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South Carolina
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Tennessee
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Utah
Vermont
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Washington
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What is your highest degree of education?* This field is required.
Please Select
Please Select
Prefer not to answer
8th grade or less
9th - 12th grade
High school grad/GED
Some college/no degree
Associate’s degree
Bachelor’s degree
Master’s degree
Doctorate degree
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What is your marital status?* This field is required.
Please Select
Please Select
Prefer not to answer
Married
Single
Divorced
Separated
Other
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How would you describe your race? Select all that apply.* This field is required.Your answer helps us raise money so we can offer discounts.
White
Black/African American
Native American
Asian/Pacific Islander
Other
Prefer not to answer
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Do you consider yourself to be Hispanic or Latina/e?* This field is required.Your answer helps us raise money so we can offer discounts.
Yes
No
Prefer not to answer
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How do you identify?* This field is required.
Mexican, Mexican-American or Chicana
Puerto Rican
Cuban
Central American
South American
Other Spanish, Hispanic or Latina
Prefer not to answer
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Other Spanish, Hispanic or LatinaPlease specify:
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How many living children do you have?* This field is required.
Please Select
Please Select
Prefer not to answer
0
1
2
3
4
5
6
7
8
9
10
More than 10
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How many spontaneous abortions (early pregnancy losses) have you had?* This field is required.
Please Select
Please Select
Prefer not to answer
0
1
2
3
4
5
6
7
8
9
10
More than 10
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How many induced abortions have you had?* This field is required.
Please Select
Please Select
Prefer not to answer
0
1
2
3
4
5
6
7
8
9
10
More than 10
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How many total previous pregnancies have you had?* This field is required.
Please Select
Please Select
Prefer not to answer
0
1
2
3
4
5
6
7
8
9
10
More than 10
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Were you using contraception at the time of conception?* This field is required.
Prefer not to answer
Yes
No
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Which birth control method were you using?* This field is required.
Please Select
Please Select
Prefer not to answer
Cervical cap
Condom (male)
Condom (female)
Contraceptive injection
Diaphragm
Foam
Hormone implant
Hormone patch
IUD
Oral contraceptive (pill)
Rhythm
Vaginal ring
Other
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Was the first day of your last period less than 6 weeks ago?
If yes, please schedule your appointment 1-2 weeks from now.

If you schedule too early (less than 5 weeks from your period), the pills fail 15 out of 100 times — meaning you stay pregnant and have to take them again.
The best results are when you are 6-11 weeks after the first day of your last period.

Don’t worry — we make sure we have open appointments, and you can book 3 weeks in advance.
Call us at (740) 448-6571‬ if you have questions

Click SUBMIT below to schedule your appointment.
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Cost language
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Cost
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Translation services
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Date and Time
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