Patient Intake Form Logo
Language
  • English (US)
  • Español
  •  / /
  •  / /
  • California Intake Form

    Video appointments are available Monday-Thursday 8am-12pm, 5pm-8pm; and Fridays 7am-12pm. Please take your time providing accurate health information.
  • Please also select your language preference from the top right corner.
    También puede seleccionar su idioma preferido en la esquina superior derecha.

  • Patients must submit their own medical information and schedule their own appointments. This is for safety and quality. Please share our website with the person needing care so they may schedule for themselves.

    We currently provide care in only English and Spanish.

    Return to AOD

     

  • We do not provide care for minors. If you are under age 18 in need of abortion care in California, please contact our friends at:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

     

  • You can miss a period for many reasons other than being pregnant. We do not require proof of a positive pregnancy test - we simply request that you do one.

    Return to AOD

     

  •  / /
  • Ultrasound (sonogram) reports have at least two pieces of information:

    1) Due date for when you would deliver should you remain pregnant

    2) How many weeks pregnant you were when the ultrasound was done.

    If you have this information available, please submit it below. If you do not have the information now, we may request it later.

  •  / /
  •  / /
  • It looks like you are very early in your pregnancy.

    Medication abortion is MORE effective after 5 weeks. 

    We advise most patients wait until they are at least 5 weeks from the first day of their last periods to take abortion pills. It is safe to take the pills early; it just might not work as well.

    Please keep this in mind when scheduling. Financial assistance is not available before 5 weeks.

  • AOD does not schedule patients who are more than 10 weeks pregnant. Please contact our friends below to schedle an in-clinic abortion:

    FPA Women’s Health

    OR

    Women’s Health Specialists

     

    Return to AOD

     

  • If you do not have regular predictable periods, there is a risk you may be further into your pregnancy than expected. Please contact our friends below to schedle an in-clinic appointment:

    FPA Women’s Health

    OR

    Women’s Health Specialists

     

    Return to AOD

  • An ectopic pregnancy, aka tubal pregnancy, happens when a pregnancy implants outside of the uterus. It is a medical emergency. If you have had an ectopic pregnancy in the past there is a bigger risk you could have one again. You should have an ultrasound (sonogram) prior to your abortion.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women’s Health

    OR

    Women’s Health Specialists

     

    Return to AOD

     

  • Bleeding in early pregnancy is a possible symptom of ectopic pregnancy, aka tubal pregnancy. You should have an ultrasound prior to your abortion.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women’s Health

    OR

    Women's Health Specialists

     

    Return to AOD

     

  • Intense cramping in early pregnancy is a possible symptom of an ectopic pregnancy, aka tubal pregnancy. You should have an ultrasound (sonogram) before your abortion.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women’s Health

    OR

    Women's Health Specialists

     

    Return to AOD

     

  • Pelvic inflammatory disease is an infection in the uterus, ovaries and/or fallopian tubes most commonly caused by sexually transmitted infections. If you have had it in the past, you are at increased risk for an ectopic pregnancy.

    If you have a history of pelvic inflammatory disease (PID), you should have an ultrasound before your abortion.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

     

  • The fallopian tubes move an egg from your ovary to your uterus. Most common reasons for surgery include cysts or tubal pregnancies.

    If you have had surgery on your fallopian tubes, you are at increased risk for an ectopic pregnancy and should have an ultrasound.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • If you got pregnant with an IUD in place, you are at increased risk for an ectopic pregnancy. You should have an ultrasound.

     Please contact our friends below to schedle an in-clinic appointment:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • Medical History

    The following questions help us confirm medication abortion is safe for you.

  • A medication abortion is not safe for people who are allergic to misoprostol (Cytotec) or mifepristone. Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • We usually provide high dose ibuprofen for pain control. If you have an allergy to ibuprofen we will replace it with Tylenol (acetaminophen). We do not prescribe narcotics.

  • Nausea is a common side effect of abortion pills. We usually provide Zofran (ondansetron) to help reduce nausea. If you have an allergy to ondansetron we can leave it out of your kit. You may use Benadryl (diphenhydramine) over-the-counter instead to manage nausea symptoms.

  • We usually provide high dose ibuprofen for pain control. If you have a sensitivity or allergy to ibuprofen we will replace ibuprofen with Tylenol (acetaminophen). We do not prescribe narcotics.

  • Bleeding disorders are rare conditions that prevent blood from clotting the way it is supposed to. It is not safe to have a medication abortion if you have a bleeding disorder. 

     Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • It may not be safe to have a medication abortion if you have severe anemia. 

     Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • It may not be safe to have a medication abortion if you take blood thinners.

    Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • The mifepristone abortion pill blocks steroids. So it is not safe to take mifepristone is you need regular steroids. We do not offer misoprostol-only abortion.

    Please contact our friends below to schedle an in-clinic appointment:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • The adrenal glands sit on top of the kidneys and make hormones. The mifepristone abortion pill blocks these hormones, so it is not safe for people who have very weak adrenal glands.

    Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • Porphyria is an extremely rare health condition effecting the liver and skin. It is not safe for people with porphyria to take the abortion pill.

    Please contact our friends below to schedle an in-clinic abortion:

    FPA Women's Health

    OR

    Women's Health Specialists

     

    Return to AOD

  • Financial Assistance

    $389 includes cost of the video visit, medication kit shipped overnight, 24/7 emergency support and routine text-based follow-up care.
  • We have partnered with several regional and national abortion funds to provide discounted services for Californians with a financial need. The following questions help us find out if you qualify for funding.

  • We offer a discounted fee of $324 and work with Access RJ to further ensure people in California can get timely abortion care regardless of their ability to pay. 

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

     Please keep in mind that MediCal in (California state Medicaid) covers telehealth abortion via other providers:

    FPA Women's Health

    Women's Health Specialists

  • Our team works hard to ensure no one gets turned away for financial reasons. Medication abortion is LESS effective before 5 weeks.

    We cannot apply financial assistance before 5 weeks.

    We may move your appointment to a time when you are at least 5 weeks pregnant to make sure funding is available.

  • Okay. Please be prepared to pay $389 at your appointment time.

    We accept Visa, Mastercard, American Express and Discover.

    Billing statements read "AOD" without any reference to abortion for your privacy.

  • Demographic Survey

    You may leave the following questions blank if you wish. Your answers will not affect your ability to get care with AOD.
  • 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 2pm Pacific.

    Payment is due at the time of the appointment. We cannot hold medication packages for more than 1 day for delayed payment. If you are in need of funding assistance, please give yourself a few extra buffer days to schedule your visit.

  • Appointment Information

  •  / /
  • *Overnight shipping is not available to P.O. Boxes. We may require a California-issued ID for shipping to non-residential addresses.

  • By entering my mobile number, I agree to receive texts from Abortion on Demand regarding my appointment and follow-up care. Message frequency varies by appointment. Message and data rates may apply. Please text STOP to unsubscribe from messages or HELP for more information, or contact us at info@abortionondemand.org for other issues. Please see our terms/conditions, privacy policy and healthcare privacy policy for more information.

  • If you want to give AOD permission to speak with a close friend or family member about your abortion care in case we cannot reach you, please provide their contact information here. Make sure this person knows you are getting abortion care.

    It is okay to leave blank if you prefer.


  • 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:

    1. It is necessary for you to provide complete and accurate medical history. Providing inaccurate history can result in serious complications. 
    2. 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.
    3. 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. 
    4. 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.
    5. 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.
    6. 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. 
    7. 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.
    8. 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.
    9. 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.

  • Clear
  • Should be Empty: