OPILL Contraception Request Form / Formulario de Solicitud de Anticonceptivo OPILL

Opill Contraception Request Form

If you live in the Gulf South (Louisiana, Texas, Mississippi, Arkansas, Florida, or other Gulf South states) and are requesting Opill daily contraception (also known as the birth control pill or the "minipill") please fill out the following form.
Is Opill right for me?

Opill is the first FDA approved over-the-counter (OTC) daily birth control pill. It is a progestin-only pill that does not contain any estrogen, so it is very important to take it at the same time every day for it to work. for more info you can check out opill.com.
Important Info

This is not an emergency service. Your package will be mailed within two weeks of receiving the request, in a discreet mailer from a P.O. Box. The packages normally contain a three-month supply of daily Opill contraceptive pills, condoms, pregnancy tests, and informational materials. Contents may vary based on availability of supplies.
Language/Idioma (Choose above/ Elige arriba)
Name*

First NameLast Name
Mailing Address (please note at this time we are only shipping to addresses in LA, TX, MS, FL, and AR)*

Mailing Address

Address Line 2

CityState

Zip Code
Phone Number (not required, but helpful if there is an error in the form and we need to contact you)
Please enter a valid phone number.
Email (not required, but helpful if there is an error in the form and we need to contact you)
example@example.com
How did you hear about us?
This medication only works when taken every day at the SAME TIME every day. It is very important to read all the instructions that come in the Opill package to ensure you are using it correctly.*

Yes, I understand.
Contraception is NOT an abortion pill. It will not impact an existing pregnancy. Please click that you understand.*

Yes, I understand.
Do we have your permission to include resources about other reproductive care in your package?*

YesNo
Please understand that we are an all-volunteer group, and there may be a time when we do not have Opill contraception in stock. If this is the case, this request form will close and/or you will receive an email communication that we currently cannot assist. Please click that you understand.*

Yes, I understand.
Do you have any questions or feedback for us? Feel free to leave it here. If it requires a response, please ensure you've left your email address for us to contact you. Thank you.
Note

*Occasionally packages are returned to sender. As an all-volunteer collective, we appreciate your help in letting us know if you don't receive your package! If you don't receive your package in 21 days, please email us at gulfsouthplanb@protonmail.com & we can look into resending.*
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Opill Contraception Request Form

Is Opill right for me?

Important Info

Note