Language
  • English (US)
  • Español
  • Português
  • French (France)
  • Somali
  • Lingala
  • Birth Control Prescription Request Form

    Needed Before Telehealth (Virtual) Appointments
  • What language do you speak?

    Please note: this form also works with Google Translate
  • Required Consent

  • Review the items below and confirm that you understand and approve the following

    During the visit, your clinician/provider can:
  • Contact Info

  •  - -Pick a Date

  • Emergency Contact

  • Insurance Information

  • Birth Control Questions

  • 0/500
  • 0/500
  • 0/500
  • Pregnant or Breastfeeding?

  • Medical History

  •  - -Pick a Date
  • 0/500
  • 0/500
  • 0/500
  • 0/500
  • Acknowledgement, Authorization & Waiver

  • Clear
  •  - -Pick a Date
  • Maine Family Planning also offers services for sexually transmitted infections (STIs), such as testing, treatment, risk reduction, and prevention (HIV PrEP). STI services are available by telehealth or in-person visits.

  • Once you hit submit, you will be taken to a scheduling page to select a time for a quick telehealth appointment. Please select ‘Medication Check’ as the reason for your visit.

  • Should be Empty: