Primary Check
Please enter the following information so we know if we have doctors available for you.
What state are you requesting treatment in?
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Sorry, but we don't have any doctors available in that state right now.
If you continue to fill out this form, we will not be able to complete your medication request. We are working hard to add more doctors to our team!
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Before continuing, please agree and accept the Terms and Conditions so we are able to properly handle your health information.
Full Name
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First Name
Middle Name (optional)
Last Name
Date
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Year
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Let us get to know you.
The following information is going to help us qualify you and give you the best treatment possible.
What is your Full Name?
*
First Name
Middle Name (optional)
Last Name
What is your phone number?
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Area Code
Phone Number
What is your Date of Birth?
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January
February
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1927
1926
1925
1924
1923
1922
1921
1920
Year
Select your Sex, we'll make sure you qualify for this treatment.
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Male
Female
Please enter your height. (Inches)
*
Please enter your weight. (Lbs)
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What is your Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this also your billing address?
*
Yes
No
Email
*
Confirmation Email
It's crucial we have the correct email for your account.
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Birth Control Request
Please give us some more information so we can process your request and match you with a doctor.
What type of Birth Control are you requesting evaluation for?
*
Please select an option
Birth Control Pills
Birth Control Patch
Birth Control Ring
Birth Control Diaphragm
Please choose which option we can help you with.
Are you currently using any birth control methods now? This includes IUDs, condoms, or any other method you may use.
*
Yes
No
What birth control methods are you currently using?
*
Please include all methods such as IUDs and condoms.
How long have you been using these birth control methods?
*
Have you missed any doses of your current birth control this month?
*
Yes
No
What can we help you do today?
*
Refill my current Birth Control method
Change to a different type of birth control
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What was the date of the first day of your last menstrual period (date you started bleeding)?
How often do you get your menstrual periods?
*
How would you describe your gender identity?
*
Male
Female
Non-Binary
Other
Do you know your blood pressure from a recently taken reading (6 months or earlier)? We need a recent and accurate reading to figure out what treatment options are safe for you. If you don't have a reading right now we will tell you how to get it and you can send it later.
*
Yes
No
What was your blood pressure at last reading? This should be two numbers. Carefully type the top (systolic) and bottom (diastolic) readings. Please enter your reading carefully, it is very important to treat you safely.
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Medical History
Give us a a background of your medical history so we can better assist you.
Do you smoke cigarettes or use other tobacco products (including vaping)?
Yes
No
Do you have any medical conditions?
*
Yes
No
Please list your medical conditions below
*
Include even any minor or recent conditions or symptoms. We need to know your full history to give you the best care. Even include things you think you have whether or not it's been diagnosed by your doctor. We will call or message you if we need more information.
Have you ever had any surgeries or hospitalizations?
*
Yes
No
What surgeries or hospitalizations did you have?
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Include any significant emergency room visits, hospital stays, or surgeries, including cosmetic surgeries.
Do you currently take any medicines, herbals, or supplements?
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Yes
No
Please list all your medicines, herbals, or supplement them below.
*
Please include any medicines you finished recently, including topical medicines, and any injections, vitamins, herbal remedies, or any other products you use.
Do you have any allergies or medication reactions?
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Yes
No
What known allergies or medication reactions do you have?
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Please include all known information so we can treat you the best way possible.
Which of the following apply to you? Certain conditions can complicate diagnosis, increase risks, or change the recommended treatments so it critical we know everything going on with your health.
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Planning to get pregnant within 12 months
Pregnant
Recently gave birth (less than 6 weeks ago)
Breastfeeding
Recovering from recent surgery
Taking Aminoglutethimide (Seizure medication)
Taking long term Corticosteroids
Unable to move easily or wheelchair bound
Being tested or treated for cancer
No, I don't have any of these conditions
How old is the baby you are breastfeeding?
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Medical History (you're almost done!)
Have you personally ever had any of the following conditions? Even if they are in the past certain conditions can complicate diagnosis, increase risks, or change the recommended treatments so it critical we know your full history.
*
Cancer
Crohn's disease or ulcerative colitis (UC)
Cushing's syndrome
Diabetes
Family history of blood clots including pulmonary embolus (PE) or deep vein thrombosis (DVT)
Gallbladder problems
Heart attack, chest pain, angina, or serious heart problems
High blood pressure (hypertension)
High cholesterol or lipids
Inflammatory bowel disease
Liver problems
Lupus or systemic lupus erythematosus (SLE)
Organ transplant
Positive anti-phospholipid antibodies
Prone to blood clots (coagulopathy)
Stroke or vascular disease
No, never had these conditions
What kind of cancer?
*
What is the current status of your cancer diagnosis/treatment?
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What is your current A1C and treatment plan?
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When did you last have your Hb A1c checked? When will you see your in-person doctor next?
Have you ever had any kidney, eye, or nerve issues related to diabetes?
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Did you have your Gallbladder removed?
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Yes
No
How well controlled is your blood pressure?
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What is the current plan to manage your blood pressure?
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Have you ever had any kidney, eye, or nerve issues related to the blood pressure? If so, please elaborate.
*
What kind of liver problems?
*
Tell us more about how you are prone to blood clots (coagulopathy).
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Last step!
We just need a little more information
Have you ever had migraine headaches? Even if they only occurred when you were younger it is important for us to know because they can increase some serious risks with certain types of birth control.
*
Yes
No, never had migraines
Will you use insurance to help pay for your medicine? You can use your insurance at the pharmacy, or if you don't have insurance we can help you find low cost options.
*
Yes
No, don't have insurance
No, I don't want to use insurance
I'm not sure
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When do you want to schedule your TeleHealth online visit?
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Checkout Time!
Once your payment is processed and the form is submitted a doctor will reach out to you shortly!
Birth Control Appointment
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Birth Control Medicine Appointment
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