Intake

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IntakeThis brief medical survey takes about 2 minutes.
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Are you the person who will receive the services?* This field is required.
Yes
No
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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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What service do you need?* This field is required.
Ultrasound to find out how pregnant I am, or to help me learn about my options
Follow-up ultrasound after abortion at our clinic in the last 3 months
Ultrasound as part of medication abortion visit
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Unique ID
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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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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 ultrasound 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.
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Today's Date
Date
Month
Day
Year
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Do you have Ohio Medicaid/Ohio Health Care Program?
YESNO
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It costs us $150 to provide you with an ultrasound. We only charge what you can afford, between $0-$150. Your visit lasts about an hour.* This field is required.
I can pay $150.
I need a discount.
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We can give you a $65 discount. Your cost would be $85.* This field is required.
I can pay $85.
I can’t pay $85 — I need more of a discount.
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What amount can you pay for your services?* This field is required.
$50
$25
$0
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Your information is kept private. We follow all state and federal privacy laws. We may send texts, emails or messages through a secure app for reminders.
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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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Name you wished to be called
if you prefer a name other than what's on your ID
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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.
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What state do you live in?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
KANSAS
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Canada
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Telehealth: Components of my visit, including interpreting the ultrasound results, may be conducted by a medical provider working remotely. I consent to receiving care through telehealth.

Ultrasound: I am scheduling an ultrasound. The purpose of this ultrasound is for pregnancy dating and to ensure the pregnancy is in my uterus, for follow-up after a miscarriage or abortion, or to help me learn about my options. It is not for other diagnostic purposes.
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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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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/Other
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Your visit at JustCenter at JustChoice usually lasts about an hour or so.

Click “Submit” below to schedule your appointment.
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Cost
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Translation services
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Date and Time
Should be Empty: