Emergency Contraception Request Form / Formulario de Solicitud de Anticonceptivo de Emergencia

Please select language in the upper right corner / Por favor elige su idioma en la esquina de arriba a la derecha

Emergency Contraception Request Form

If you live in the Gulf South (Louisiana, Texas, Mississippi, Arkansas, or Florida) and are requesting emergency contraception (also known as "Plan B" or the "morning after pill") please fill out the following form. This is not an emergency service. Your package will be mailed within two weeks of receiving the request, in a package from a P.O. Box. PLEASE NOTE: Emergency contraception can help prevent pregnancy if taken within 72 hours after unprotected sex. It is more effective the sooner it is taken. Afterpill (levonorgestrel) is considered to be less effective for people over 160 lbs. The packages normally contain two (2) doses of emergency contraception, four (4) pregnancy tests, and informational materials.
PRIORITIZING OUTSIDE OF NEW ORLEANS

Please note at this time we are prioritizing requests from outside of Orleans Parish. For Emergency Contraception in Orleans Parish, please see @porch_store on Instagram or https://www.planbnola.com/. If you are unable to access EC through those resources, we are still happy to mail to you.
Language/Idioma
Name*

First Name Last 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

City State

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? *
Please understand that we will only ship a package to an address once every 4 months. Please click that you understand.*

Yes, I understand.
Please understand that we are an all-volunteer group of individuals, and there may be a time when we do not have emergency contraception in stock. If this is the case, you will receive an email communication that we currently cannot assist. Please click that you understand.*

Yes, I understand.
Emergency 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
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.
Do you know of a community group anywhere in Louisiana who would like to partner to distribute Plan B? If it requires a response, please ensure you've left your email address for us to contact you. Thank you & take care.
Should be Empty:

Emergency Contraception Request Form

PRIORITIZING OUTSIDE OF NEW ORLEANS