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AOD Stage
Patient Intake Form
2
Questions
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HIPAA
Compliance
1
UniqueID
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2
CogsworthServiceID
*
This field is required.
This is the ID of the service in Cogsworth corresponding to this form.
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3
WebsiteURL
*
This field is required.
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4
In which US state are you located?
*
This field is required.
This does not have to be the state in which you live. Rather, it has to be the location for completing your virtual appointment and where you will receive your medication kit by mail. Find out more about US states that allow abortion by mail on our
FAQ
.
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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5
How old are you?
*
This field is required.
You will need to provide your ID with date of birth during your virtual appointment.
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6
IneligibilityReason
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