Birth Control Prescription Request Form

Emergency Contact
Emergency Contact's Name

Enter Emergency Contact's First NameEnter Emergency Contact's Last Name
Enter Their Phone Number
Type Emergency Contact's Phone Number
Secondary Phone Number
If Emergency Contact has two numbers

Birth Control Questions
Have you used birth control in the past?*

YesNo
If you answered YES, what method of birth control have you used?

Enter the name of the birth control medication0/500
If you answered NO, what kind of birth control do you desire?

0/500
Do you have any birth control questions?

0/500

Acknowledgement, Authorization & Waiver
Acknowledgment*

I acknowledge that all information I provided in this form is true and accurate
Authorization*

I authorize Maine Family Planning to contact me and provide treatment regarding the submission of this form.
Waiver*

I understand the risk and complications if I do not follow the instructions given to me after the telehealth (virtual) appointment, which involves post-treatment and follow-ups.
Patient Signature*

Clear
Date Signed*

MMDDYYYY
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:

What language do you speak?