Intake

IntakeThis brief medical survey takes about 2 minutes.

Are you the person who will receive the services?* This field is required.

Yes

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.

Date of Birth* This field is required.

as listed on your photo ID

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.

You must have a positive pregnancy test before scheduling an appointment. An inexpensive drug store urine test works well. A doctor's office visit is not required to do a 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.

Do you need an interpreter? If so, select the language.

Do any of these apply to you?* This field is required.

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)

No, I have none of these problems.

It may not be safe for us to offer you miscarriage management services. Please call us to discuss at (740) 448-6571‬ and we can review your particular situation. Or you can contact a local community health clinic or OBGYN to get care. We are happy to help; call us.

Are you having such heavy bleeding that you feel dizzy, or you are soaking more than 2 pads an hour?

Yes

We recommend going to the emergency room. You need urgent treatment. Please call us if you need help figuring out where to go: (740) 448-6571‬. If you cannot reach us, then go to the nearest emergency room without delay.

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.

We cannot help you with your miscarriage if you are more than 12 weeks pregnant. We recommend you get care from an OBGYN: please call us if you need help finding a provider: (740) 448-6571‬.

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.

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.

Today's Date

Date

Do you have Ohio Medicaid/Ohio Health Care Program?

YESNO

It costs us $490 to provide you with miscarriage treatment. We only charge 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.* This field is required.

I can pay $490.

I need a discount.

How many people live in your household?* This field is required.

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.

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.

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.

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.

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.

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.

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.

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.

We can give you $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.

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.

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.

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.

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.

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.

$50

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.

What is your first name?* This field is required.

as it appears on your ID

What is your last name?* This field is required.

as it appears on your ID

Name you wished to be called

if you prefer a name other than what's on your ID

Phone Number* This field is required.Please provide the best phone number to reach you. We will send appointment confirmations to this number. Carrier rates for SMS texts may apply. We will never share your number outside of our system or use it for marketing purposes.

Please enter a valid phone number.

What state do you live in?* This field is required.

We only offer medications to treat miscarriages. After your visit, we will send you a follow-up survey by text. Miscarriage can also be treated by a procedure; if you want a procedure you need to contact another provider.* This field is required.

We only treat miscarriage 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.

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 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.

Medication treatment of miscarriage is extremely safe, even safer than Tylenol. Rare but serious risks of 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 rare – and it is many times more common than death from miscarriage* This field is required.

There is a very small chance that the medications do not work and you need further treatment. If this happens, we will help you 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.

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.

Where do you want your appointment? Columbus: Thursdays (12/22 and 12/29 holiday hours). Cincinnati: Fridays and Saturdays.* This field is required.

show me only Columbus appointments

show me only Cincinnati appointments

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

Referred/OtherPlease specify:

You can choose appointments in Columbus or Cincinnati.

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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