SHORT CAYA FORM

1

Please choose from one of the options below that best describes your needs:

1) I need a Caya prescription, click here

2) I have questions about Caya, click here

3) I have a Caya Prescription to fill via mail order, click here

If you have any additional questions/concerns, or do not know which option to choose, text us at 725 228 8277, or call 888 224 0804.

2

Email* This field is required.

example@example.com

3

Which one of these best applies to you?* This field is required.You can call us at 888 224 0804 or text us at 725 228 8277 if you need help figuring out which category best suits you.

I do not yet have a prescription for CAYA and need a physician to initiate the prescription.

I already have a prescription for CAYA but I need to be connected to a pharmacy to get it filled.

4

Do you have an established PCP or OBGYN?* This field is required.

YESNO

5

If YES have you spoken with them about the CAYA diaphragm?

YESNO