Patient Intake Form - District of Columbia

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UniqueID
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CogsworthServiceID* This field is required.
This is the ID of the service in Cogsworth corresponding to this form.
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AcuityAppointmentType* This field is required.
This is the ID of the appointment type in Acuity
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Configuration* This field is required.
Configuration flags
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Date* This field is required.
Date
Month
Day
Year
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EarliestMenstruationEligibilityDate* This field is required.
Date
Month
Day
Year
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Washington DC Intake Form

This is the intake for District of Columbia patients ONLY. If you are seeking care from other location, please go to abortionondemand.org and select your state from the drop down menu.
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How Medication Abortion Works with AODWe recommend reviewing AOD's instructional video. It it available on our homepage as well. To skip, click "NEXT".
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In which US state are you located?* This field is required.Software used during your video appointment will confirm your location for regulatory compliance.
District of Columbia
Please Select
California
Colorado
Connecticut
Delaware
District of Columbia
Hawaii
Illinois
Kansas
Maine
Maryland
Massachusetts
Minnesota
Montana
Nevada
New Hampshire
New Jersey
New Mexico
New York
Oregon
Pennsylvania
Rhode Island
Vermont
Virginia
Washington
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How old are you?* This field is required.We will need to see your photo ID with date of birth during your virtual appointment. If you do not have an ID, please see our resources page for other care options.
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On what day did your last menstrual period start?* This field is required.
Date
Month
Day
Year
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Do you have access to a smart phone with a video camera?* This field is required.We need to do a secure video consultation then be able to reach you if needed after your appointment.
YESNO
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Did you have a positive home pregnancy test?* This field is required.There are many things other than pregnancy that can cause missed periods.
YESNO
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IneligibilityReason
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Location RequirementThe only exception to the following location requirement are patients in Washington, D.C. picking up medications in Maryland.
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Terms and Conditions* This field is required.We rely on patients self-reporting accurate medical history to ensure safe abortion care. By proceeding you understand that this intake is used to create your formal medical record and you agree to provide accurate medical information. You understand that - due to the remote nature of our service - we may not permit repeat intakes with varying information, even if entered in error. Only prospective patients may submit their own intakes. You are not permitted to submit medical information for someone other than yourself. We review each scheduled appointment for safety and legal compliance. If safety or legal concerns arise, we may refer you to another care provider.
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For friends and well-meaning partners:* This field is required.I am the patient filling out my OWN medical information. I understand that if this form is completed by someone other than the patient the appointment will be CANCELLED without the opportunity to reschedule. I understand that I am providing a legally binding signature and that it may be a crime to impersonate someone else.
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Have you had an ultrasound for this pregnancy?* This field is required.Most people do not need an ultrasound for early abortion care. If you had an ultrasound for this pregnancy it would have been reported to you based on the number of weeks into your pregnancy you were and/or your expected due date if you were to continue the pregnancy. The doctor may ask to see the report during your visit.
No.
Yes - and it was normal.
Yes - but you could not see the pregnancy.
I don't know.
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Do you know your due date from the ultrasound?Leave blank if you do not know the due date.
Date
Month
Day
Year
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Do you know how many weeks along you are from the ultrasound?Leave blank if you don't know.
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Before this pregnancy, how predictable were your menstrual periods?* This field is required.Please select the option that fits best.
I have a period about the same time every month. I have not missed periods in the year prior to this pregnancy.
I have a period about once a month but have skipped periods several times in the last year.
My periods are hard to predict.
I don't know.
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Have you ever had an ectopic pregnancy?* This field is required.These are pregnancies outside of the uterus, sometimes called a tubal pregnancy.
No
Yes
I don't know
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You said you have had an ectopic pregnancy in the past. To be clear, have you ever had an ectopic pregnancy before?These are also known as tubal pregnancies and are a medical emergency.
Yes, I have had an ectopic pregnancy before.
No, that was an error. I’ve never had an ectopic pregnancy.
I don't know.
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ContactUltrasoundPlease leave this blank or click NEXT.
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Have you had bleeding since finding out you were pregnant?* This field is required.
No
Yes
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You reported you have had bleeding with this pregnancy. To be clear, have you been bleeding? It’s important that we have accurate information.
Yes, I have been bleeding.
No, that was an error. I have not had bleeding with this pregnancy.
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Are you having pain or heavy cramping?* This field is required.
No
Yes
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You reported you are having pain or heavy cramping. To be clear, are you having pelvic pain? It’s important that we have accurate information.
Yes, I have pelvic pain.
No, that was an error. I am not having any pain.
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Have you ever had PID (pelvic inflammatory disease)?* This field is required.Pelvic inflammatory disease is an infection in the uterus, ovaries and/or fallopian tubes most commonly caused by sexually transmitted infections.
No
Yes
I don't know
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Have you ever had surgery on your fallopian tubes?* This field is required.
No
Yes
I don't know
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Do you currently have an IUD? Or did you have an IUD when you got pregnant?* This field is required.An intrauterine device (IUD) is a small device that is placed inside the uterus to prevent pregnancy.
No
Yes
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Please tell us which medications you are allergic to.* This field is required.More information about NSAIDs, Prostaglandins and Mifepristone is on our FAQ page.
I am not allergic to any medications.
NSAIDs (includes ibuprofen and naproxen)
Prostaglandins (includes misoprostol)
Zofran (ondansetron)
Other
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Please select which of the following medical conditions you have.* This field is required.More details about these rare conditions can be found on our FAQ page.
I have a bleeding disorder; examples include Von Willibrand disease.
I take blood thinners.
I have serious heart problems requiring medications or procedures.
I have adrenal problems.
I have needed a blood or iron transfusion for severe anemia.
I don't know.
I do not have any of these conditions.
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ContactMedicalPlease leave this blank or click NEXT
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For whom are you booking this appointment?* This field is required.
I am the patient. I am booking this appointment for myself.
I am a friend or family member. I am booking this appointment on behalf of the patient.
I am the patient's partner. I am booking this appointment for my girlfriend, spouse or partner.
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AOD doesn't accept Medicaid or private health insurance of any kind. Will the $289 cost for AOD's services be a financial hardship for you?We work directly with abortion funds to help reduce financial burdens whenever possible.
No, I will not be needing financial assistance.
Yes, please refer me to abortion funds for financial assistance.
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AOD does not accept Medicaid or private health insurance of any kind. Will the $339 cost for AOD's services be a financial hardship for you?We work directly with abortion funds to help reduce financial burdens whenever possible.
No, I will not be needing financial assistance.
Yes, please refer me to abortion funds for financial assistance.
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AOD does not accept Medicaid or private health insurance of any kind. Will the $289 cost for AOD's services be a financial hardship for you?We have partnered with SAFE Maine (safemaine.org) to offer financial assistance to Mainers who are unable to pay the full cost of their abortion care. Please consider donating at safemaine.org if you are able to pay full price and want to help other Mainers.
No, I will not be needing financial assistance.
Yes, please release some of the SAFE Maine funds to help me cover the cost.
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AOD does not accept Medicaid or private health insurance of any kind. Will the $289 cost for AOD's services be a financial hardship for you?We have partnered with Cobalt Abortion Fund (cobaltaf.org) to offer financial assistance to Coloradans who are unable to pay the full cost of their abortion care. Please consider donating at cobaltaf.org if you are able to pay full price and want to help other Coloradans.
No, I will not be needing financial assistance.
Yes, please release some of the Cobalt Abortion Funds funds to help me cover the cost.
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AOD does not accept Medicaid or private health insurance of any kind. Will the $289 cost for AOD's services be a financial hardship for you?We have partnered with The REACH Fund of Connecticut (reachfundct.org) to offer financial assistance to people in Connecticut who are unable to pay the full cost of their abortion care. Please consider donating to The REACH Fund of Connecticut if you are able to pay full price and want to help other people in Connecticut.
No, I will not be needing financial assistance.
Yes, please release some of the REACH funds to help me cover the cost.
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AOD does not accept Medicaid or private health insurance of any kind. Will the $389 cost for AOD's services be a financial hardship for you?We work directly with abortion funds to help reduce financial burdens whenever possible.
No, I will not be needing financial assistance.
Yes, please refer me to abortion funds for financial assistance.
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AOD can offer a lower $239 fee for patients in need.

Payment is due at the time of service. We cannot hold medication kits for lack of funding and respectfully ask that you select an appointment well enough in advance to secure funds as needed. We will provide further financial resources via email after confirming your appointment.

Click NEXT to proceed.
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AOD can offer a lower $289 fee for patients in need.

Payment is due at the time of service. We cannot hold medication kits for lack of funding and respectfully ask that you select an appointment well enough in advance to secure funds as needed. We will provide further financial resources via email after confirming your appointment.

Click NEXT to proceed.
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AOD can offer a lower $189 fee for patients in need.

Payment is due at the time of service. We cannot hold medication kits for lack of funding and respectfully ask that you select an appointment well enough in advance to secure funds as needed. We will provide further financial resources via email after confirming your appointment.

Click NEXT to proceed.
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Your visit will cost $289.00. Will you be able to pay $289.00 at the time of your visit?* This field is required.
Yes. I am able to pay $289.00 at the time of my visit.
No. I need additional funding for my visit.
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Your visit will cost $289.00. Will you be able to pay $289.00 at the time of your visit?* This field is required.
Yes. I am able to pay $289.00 at the time of my visit.
No. I need additional funding for my visit.
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Your visit will cost $389.00. Will you be able to pay $389.00 at the time of your visit?* This field is required.
Yes. I am able to pay $389.00 at the time of my visit.
No. I need additional funding for my visit.
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Your visit will cost $339.00. Will you be able to pay $339.00 at the time of your visit?* This field is required.
Yes. I am able to pay $339.00 at the time of my visit.
No. I need additional funding for my visit.
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We can offer a discounted visit cost of $239.00. Will you be able to pay that amount at the time of your visit?* This field is required.
Yes. I am able to pay $239.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the Cobalt fund in Colorado and can offer a discounted visit cost of $189.00. Will you be able to pay that amount at the time of your visit?* This field is required.
Yes. I am able to pay $189.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the SAFE fund in Maine and can offer a discounted visit cost of $189.00. Will you be able to pay that amount at the time of your visit?* This field is required.
Yes. I am able to pay $189.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the NJAAF fund in New Jersey and can offer a discounted visit cost of $189.00. Will you be able to pay that amount at the time of your visit?* This field is required.
Yes. I am able to pay $189.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the WHEF fund in Rhode Island and can offer a discounted visit cost of $239.00. Will you be able to pay that amount at the time of your visit?* This field is required.
Yes. I am able to pay $239.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the Kansas Abortion Fund and with their support we can offer a discounted visit cost of $189.00. Will you be able to pay $189.00 at the time of your visit?* This field is required.
Yes. I am able to pay $189.00 at the time of my visit.
No. I need additional funding for my visit.
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We work with the Abortion Liberation Fund and with their support we can offer a discounted visit cost of $289.00. Will you be able to pay $289.00 at the time of your visit?* This field is required.
Yes. I am able to pay $289.00 at the time of my visit.
No. I need additional funding for my visit.
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This fund will support patients who need additional funds. Please indicate how much you would be able to pay for your appointment.* This field is required.
$100.00
$50.00
$0.00
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We work with funds around the country to try to make sure all patients seeking abortions can get care.

Please schedule your appointment at least 24 hours from now so you will have time to connect with these funds before your visit.

After selecting an appointment time, read the email confirmation and follow the instructions for getting additional funding so that we will not have to delay or cancel your visit.

Click NEXT to proceed.
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We work with Our Justice Fund in Minnesota to help with your costs for care. Please follow the directions in your email after scheduling to reach out to Our Justice directly so that they can provide financial assistance.

Click NEXT to proceed.
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The Kansas Abortion Fund will support patients who need additional funding. You will not owe a fee at your visit time.

Click NEXT to proceed.
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Visit Cost
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Okay. Please be prepared to pay ${visitCost} at your appointment time.

Click NEXT to proceed.
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We’re almost ready to get you scheduled with one of our experienced clinicians. There are some confidential questions we are legally required to ask. Though we have to ask, you do not have to answer. The following questions will in no way affect your ability to get care with AOD. You may leave them blank if you wish.

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No podemos brindar atención en español de manera segura en este momento. Consulte nuestra página de recursos para conocer las opciones de atención en español.
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Are you a resident of the state of Nevada?This does not alter your ability to get care with AOD in any way.
YESNO
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If you have a primary care provider (PCP), please provide contact information here.You can leave blank if you do not have a PCP or do not wish to provide this information.
Provider Name
Address
Phone
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How many children have you given birth to?
I do not want to answer.
Please Select
I do not want to answer.
0
1
2
3
4
5
6
7
8
9+
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How many living children do you have now?
I do not want to answer
Please Select
I do not want to answer
0
1
2
3
4
5
6
7
8
9+
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Not counting this pregnancy, how many prior abortions have you had?
I do not want to answer
Please Select
I do not want to answer
0
1
2
3
4
5
6
7
8
9+
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How many times have you miscarried naturally?
I do not want to answer
Please Select
I do not want to answer
0
1
2
3
4
5
6
7
8
9+
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Starting at first grade and going through to graduate education, how many years of school have you finished?(12 = high school)
I do not want to answer
Please Select
I do not want to answer
Less than 8
8
9
10
11
12
13
14
15
16
17+
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Do you consider yourself to be Hispanic or Latinx?
I do not want to answer
Please Select
I do not want to answer
Yes
No
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Please specify.You may leave blank/skip if you do not wish to answer.
Mexican/Mexican American/Chicana
Puerto Rican
Cuban
Other
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How would you describe your race?Leave blank if you do not wish to answer.
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Are you married?You may skip this question if you do not wish to answer.
Yes, I am married.
No, I am not married.
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What is your sexual orientation?You may skip this question if you do not wish to answer.
Heterosexual
Homosexual
Bisexual
Decline to answer
Other
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What is your current gender identity?You may skip this question if you do not wish to answer.
Female
Male
Non-Binary/Non-Conforming
Decline to answer
Other
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What best describes your relationship status?
I do not want to answer
Please Select
I do not want to answer
Single
Married
Civil Union
Partnered
Separated
Divorced
Civil Union Dissolved
Widowed
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What is the highest level of education you have completed?You may skip this question if you do not wish to answer.
I do not want to answer
I do not want to answer
8th grade or less
9th-12th grade; no diploma
High school graduate or GED
Some college credit, but no degree
Associate's degree
Bachelor's degree
Master's degree
Doctorate or professional degree
I don't know
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Other than English, what languages do you speak?We only offer appointments in English at this time. We must be able to speak directly with patients in English. Family members and partners cannot serve as interpreters due to anti-coercion laws. This question is part of abortion reporting required by the state of Connecticut.
American Sign Language (ASL)
Armenian
Chinese, Cantonese
Chinese, Mandarin
French (including Cajun, Patois)
French Creole (for example, Haitian)
Gujarathi
Khmer
Korean
Laotian
Persian
Polish
Portuguese
Russian
Serbo-Croatian
Spanish
Vietnamese
Other
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Thanks for that information.

Now let’s get you scheduled with one of our experienced clinicians.

Most visits take about 15 minutes. Evening appointments are available for convenience. But all medication packets are shipped out overnight Monday-Friday approximiately 5pm Eastern time after the video visit is completed. Overnight shipping is via airplane, and delivery delays are more common around the holidays due to strain on shipping companies beyond our control.

We have noticed an increase in patients since the Dobbs decision. We are working hard to accomodate a high demand of appointment requests. Please do not call requesting an earlier appointment. Our scheduling system will show you the earliest appointment available.

Payment is due at the time of the appointment. We cannot hold medication packages for more than 2 days for delayed payment. If you are in need of funding assistance from the options on our resources page, please give yourself a few extra buffer days to schedule your visit.
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Thanks for that information.

Now let’s get you scheduled with one of our experienced physicians.

Most visits take about 15 minutes. Evening appointments are available for convenience. But all medication packets are shipped overnight Monday-Friday approximately 4pm.

We have noticed an increase in patients from all states since the Dobbs decision. We are working hard to accomodate a high demand of appointment requests. Please do not call requesting an earlier appointment. Our scheduling system will show you the earliest appointment available.

Payment is due at the time of the appointment. We cannot hold medication packages for more than 2 days for delayed payment. If you are in need of funding assistance from the options on our resources page, please give yourself a few extra buffer days to schedule your visit.
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Name* This field is required.Your name as it appears on your ID.
First Name
Last Name
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Date of birth* This field is required.You must be over 18, and you will have to present your ID during your visit for additional age and identify verification.
Date
Month
Day
Year
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Mailing Address* This field is required.This is where your medication abortion kit will be sent after your appointment. It MUST be a valid residential address in the SAME state as your intake. We cannot ship to P.O. boxes, business addresses or shipment centers. We will CANCEL any appointments made using a shipping center, mail forwarding service or post office, and you will may be permitted to use our service in the future. Thank you for your understanding.
Street Address
Street Address Line 2
City
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
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
84
Is your address within city limits?
Yes
No
I don't know
85
In which Colorado county is your address?
Adams
Alamosa
Arapahoe
Archuleta
Baca
Bent
Boulder
Broomfield
Chaffee
Cheyenne
Clear Creek
Conejos
Costilla
Crowley
Custer
Delta
Denver
Dolores
Douglas
Eagle
El Paso
Elbert
Fremont
Garfield
Gilpin
Grand
Gunnison
Hinsdale
Huerfano
Jackson
Jefferson
Kiowa
Kit Carson
La Plata
Lake
Larimer
Las Animas
Lincoln
Logan
Mesa
Mineral
Moffat
Montezuma
Montrose
Morgan
Otero
Ouray
Park
Phillips
Pitkin
Prowers
Pueblo
Rio Blanco
Rio Grande
Routt
Saguache
San Juan
San Miguel
Sedgwick
Summit
Teller
Washington
Weld
Yuma
86
In which Kansas county is your address?
Allen
Anderson
Atchison
Barber
Barton
Bourbon
Brown
Butler
Chase
Chautauqua
Cherokee
Cheyenne
Clark
Clay
Cloud
Coffey
Comanche
Cowley
Crawford
Decatur
Dickinson
Doniphan
Douglas
Edwards
Elk
Ellis
Ellsworth
Finney
Ford
Franklin
Geary
Gove
Graham
Grant
Gray
Greeley
Greenwood
Hamilton
Harper
Harvey
Haskell
Hodgeman
Jackson
Jefferson
Jewell
Johnson
Kearny
Kingman
Kiowa
Labette
Lane
Leavenworth
Lincoln
Linn
Logan
Lyon
Marion
Marshall
McPherson
Meade
Miami
Mitchell
Montgomery
Morris
Morton
Nemaha
Neosho
Ness
Norton
Osage
Osborne
Ottawa
Pawnee
Phillips
Pottawatomie
Pratt
Rawlins
Reno
Republic
Rice
Riley
Rooks
Rush
Russell
Saline
Scott
Sedgwick
Seward
Shawnee
Sheridan
Sherman
Smith
Stafford
Stanton
Stevens
Sumner
Thomas
Trego
Wabaunsee
Wallace
Washington
Wichita
Wilson
Woodson
Wyandotte
87
In which Delaware county is your address?
Kent
New Castle
Sussex
88
In which Illinois county is your address?Please disregard the number listed with each county. It is for state reporting purposes only.
Adams (001)
Alexander (003)
Bond (005)
Boone (007)
Brown (009)
Bureau (011)
Calhoun (013)
Carroll (015)
Cass (017)
Champaign (019)
Christian (021)
Clark (023)
Clay (025)
Clinton (027)
Coles (029)
Cook (031)
Crawford (033)
Cumberland (035)
DeKalb (037)
DeWitt (039)
Douglas (041)
DuPage (043)
Edgar (045)
Edwards (047)
Effingham (049)
Fayette (051)
Ford (053)
Franklin (055)
Fulton (057)
Gallatin (059)
Greene (061)
Grundy (063)
Hamilton (065)
Hancock (067)
Hardin (069)
Henderson (071)
Henry (073)
Iroquois (075)
Jackson (077)
Jasper (079)
Jefferson (081)
Jersey (083)
Jo Daviess (085)
Johnson (087)
Kane (089)
Kankakee (091)
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90
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91
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92
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93
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94
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95
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96
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97
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98
On which Hawaiian island do you live?
99
Are you a resident of the state of Massachusetts?This does not alter your ability to get care with AOD in any way.
YESNO
100
Email* This field is required.AOD will send scheduling reminders and medication information to this account. It should be an email ONLY YOU can access.
example@example.com
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101
Great. Let's make sure we get your correct phone number.* This field is required.Please enter your cell phone number. You'll get a confirmation code from AOD shortly. (Message and data rates apply.)
102
Old phone fieldPlease enter your cell phone number. You'll get a confirmation code from AOD shortly. Message and data rates apply.
103
Word has been spreading fast since we launched in April 2021. How did you hear about AOD (Abortion On Demand)?select all that apply
PlanCPills.org
Google search
news article (New York Times, Marie Claire, Salon.com, Ms Magazine, etc)
Tik Tok
Instagram
Referral from a friend
Referral from my clinician
Abortion Care Network
National Abortion Federation
abortionfinder.org
ineedana.com
I'd rather not say
Other
104
Telemedicine Consent

Today you are requesting Abortion On Demand’s telemedicine services (“Services”). Telemedicine is the practice of medicine that involves the use of electronic communications to diagnose or treat patients who are in different locations than their healthcare providers. When using these Services you will be treated by and enter into a patient-clinician relationship with a clinician licensed in your state.

The expected benefits of using telemedicine for your abortion care include:

Improved and quicker access to medical care through reduced travel and visit time.

Ability to access care from any location in your state, provided it is a state in which Services are offered.

More efficient medical evaluation and management.

The potential limitations associated with using telemedicine for abortion care include:

Delays in medical evaluation and treatment due to failures in technology, such as power outages and disconnected internet.

Information may be lost due to technical failures.

Despite reasonable precautions, unauthorized persons could interrupt the transmission or electronic storage of your medical information.

In rare cases, a lack of access to complete medical information may result in adverse drug interactions, allergic reactions, or other complications including undiagnosed or delayed diagnosis of ectopic pregnancy and maternal alloimmunization.

The inability to have direct, physical contact with your healthcare provider is the primary difference between telemedicine and in-person health care. The alternative to telemedicine is receiving care in a traditional in-person care setting. Traditional in-person care for abortion may include ultrasound diagnosis for confirming gestational age, confirming pregnancy location and to rule out ectopic pregnancy; laboratory testing as indicated, and the option for surgical management of your abortion.

Abortion On Demand uses the services of three US-based mail order pharmacies for dispensing medications. Depending on your state, you may have medications dispensed by (a) American Mail Order Pharmacy, (b) Honeybee Health, or (c) Manifest Pharmacy. You may opt to use a different pharmacy of your choosing for medications other than mifepristone by notifying the clinician during your appointment. Whereas our pharmacy partners exclusively manage, store, and ship mifepristone on behalf of the healthcare provider, another pharmacy cannot be used for shipping mifepristone.

In receiving the telemedicine Services, you understand and agree:

It is necessary for you to provide complete and accurate medical history. Providing inaccurate history can result in serious complications.

You cannot use our telemedicine Services for care beyond the scope of first-trimester medication abortion. We do not offer prescriptions for DEA controlled substances.

You cannot use telemedicine Services for life-threatening emergencies. If you think you are experiencing a medical emergency, you need to call 911 or go immediately to the closest emergency room.

There is no guarantee that you will be treated by a clinician. The clinician reserves the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the clinician, the provision of the services is not medically or ethically appropriate.

You understand that a variety of alternative methods of medical care may be available to you and that you may choose one or more of these at any time. These include in-person medication abortion, surgical abortion, parenting, or adoption.

You understand that you have the right to withhold or withdraw your consent to the use of telemedicine in the course of your care at any time, without affecting your right to future care or treatment.

You have the right to receive medication counseling from a pharmacist directly, and you may notify the clinician during your visit if you wish to exercise this right.

You will be required to provide full payment prior to receiving medications. You understand that other payment models for abortion care are available including health insurance, but that these options are beyond the scope of this Service. Refunds cannot be provided after medications have been shipped.

You consent to use text and personal email to communicate about your care with Abortion On Demand. SMS and data charges may apply, depending on your carrier. You may contact info@abortionondemand.org to opt-out of SMS notifications. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. You should not include personal identifying information such as your birth date or personal medical information in any emails you send to us.

Your use of this service is voluntary and you have the right to withdraw your consent to the services at any time. If you choose to end your session or cancel your appointment, your right to future telemedicine Services will not be affected. Information collected and stored in the medical record may be used in the future for quality improvement or other research purposes. All information will be anonymous; your personal information will not be used or shared without your consent.
105
I have read and understand the Telemedicine Consent; I agree to the terms therein. I confirm I am booking an appointment for myself and not another individual. I understand I must be in the state selected during my video appointment.
Clear
106
Are you sure of your decision and that no one is forcing you to seek an abortion?* This field is required.If you are not sure, please see our resources page for other care options. You will be redirected to our secure scheduling page for booking.
Yes, I am sure of my decision.
107
Please note we are able to provide care for adults only in specific U.S. states* This field is required.
I acknowledge
108
End
109
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Washington DC Intake Form

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