• Date of Birth*
     - -
  • What was your gender at birth?*

  • Please discontinue the visit. This visit is only available for female individuals. 


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  • Format: (000) 000-0000.

  • TERMS OF SERVICE

  • *

  • Advanced Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor. 

  • 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.*
  • Please select one of the following:*
  • Is there a preferred birth control you would like to start on?*
  • Which method(s) of birth control do you prefer? (Select ALL that apply)*

  • In some cases, the preferred birth control medication may not be prescribed. Birth control is selected by the provider based on safety and effectiveness. 

  • Please tell us the reason for seeking birth control. (Select ALL that apply)*
  • Did you give birth in the last 6 weeks?*
  • Was your last menstrual period more than a month ago?*
  • Have you forgotten to take the birth control at any time during the last 4 weeks?*
  • Please choose the option that best describes your situation in the last 4 weeks:*
  • Is the late period expected due to you being on birth control pills?*
  • Have you been sexually active in the last 4 weeks?*

  • If you have not had a 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 your local pharmacy. 

  • What was the result of the pregnancy test?*

  • PLEASE DISCONTINUE THIS VISIT AND SCHEDULE AN APPOINTMENT WITH AN OBGYN FOR EVALUATION OF PREGNANCY

  • People with high blood pressure should not take some types of birth control medication. For this reason, it is important that we have a recent and accurate blood pressure reading. 

  • Has your blood pressure been taken within the last month?*

  • It is essential that a recent and accurate reading of your blood pressure is provided. People with high blood pressure are at increased risk of complications when on certain types of birth control medications. If you do not have a blood pressure monitor at home, your blood pressure can be checked for free at most pharmacies and fire stations. 

  • After the blood pressure is checked, please resume this visit and enter your blood pressure.*

  • A blood pressure reading contains 2 numbers written like a fraction (e.g., 120/80; read as "120 over 80"). The higher number (120) is the "systolic" blood pressure. The lower number (80) is the "diastolic" blood pressure. 

  • This visit does not guarantee a prescription refill. The provider will determine if a refill is medically appropriate and how many refills can be prescribed. In some cases, the preferred birth control medication may not be prescribed. Birth control is selected by the provider based on safety and effectiveness. 

  • MEDICAL HISTORY

  • People with certain medical conditions are at an increased risk of major side effects when on some birth control medications.

  • Do you have any of the following medical conditions? (Select ALL that apply)*
  • Do you have a history of any of the following? (Select ALL that apply)

  • The risk of using certain medications with birth control medications may outweight the benefits. 

  • Do you currently take any of the following medications? (Select ALL that apply)*
  • Do you smoke or use smokeless tobacco?*
  • Do you have diabetes?*
  • Have you had a hemoglobin A1C taken in the last 6 months?*
  • Please select the HgbA1c range that accurately reflects your result.*
  • 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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