Emergency Contraception Telemedicine Visit
  • Date of Birth*
     - -

  •
  • Format: (000) 000-0000.
  • What was your gender at birth?*

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • Was your last menstrual period more than a month ago?*
  • Is the late period expected due to you being on birth control?*
  • Have you been sexually active in the last 4 weeks?*


  • If you have NOT had your period in the past month, we ask that a pregnancy test be taken before being prescribed any medications. Home pregnancy tests can be obtained at any pharmacy. 

  • After a pregnancy test has been taken, please return to this visit.*
  • What was the result of the pregnancy test?*
  • When did you last have unprotected sex?


  • Have you used the following emergency contraception in the past 30 days?

  • Plan B One-Step (levonorgestrel)*
  • Ella*
  • Do you smoke or use smokeless tobacco?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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