SHORT CAYA FORM

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

1) If you do not have a doctor or your doctor won't /can't prescribe you the CAYA and you need a prescription, click here

2) If you have a provider and already have a prescription but you're having trouble filling it and need our help, click here

3) If you are just not sure what you want to do for contraception and desire a consult with a provider versed in contraception, click here

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

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Email* This field is required.

example@example.com

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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.

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

YESNO

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

YESNO