Birth Control

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

Do any of these apply to you?*

Younger than 18 years of age
35 years or older who smokes
None of the above apply to me

Unfortunately we cannot proceed with your request based on the information you have provided.

Last day of your most recent menstrual period:*

Safety Information:*

Smoke cigarettes or use tobacco daily
You or a family member are diagnosed with one of the following: Blood clotting disorders, Deep vein thrombosis (DVT), Pulmonary embolism
Diagnosed with liver disease or liver tumor
Abnormal uterine or vaginal bleeding
None of the above apply to me

Unfortunately we cannot proceed with your request based on the information you have provided.

Most recent blood pressure reading less than 140/90?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

Date of last blood pressure reading*

Have you ever taken birth control?*

Yes
No

How long ago?*

What birth control were you prescribed?*

Oral contraceptive
Patch
NuvaRing
Other

Please list the birth control prescribed:*

Would you prefer the same prescription?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Unfortunately we cannot proceed with your request based on the information you have provided.

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

Scan/Upload any Relevant Medical Images:*

Max. file size: 32 MB.

Please upload a urine pregnancy test result to receive a Birth control therapy.

Email

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Birth Control

Birth Control

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