Birth Control Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
Gender*
Female Male
What prescription or OTC medications are you taking? Also include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.*
What is your present birth control method? *










When was the first day of your last menstrual period?*
Could you be pregnant? *


Have you recently given birth? If so , please enter the date*


Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120 / Diastolic 80*
Please re-enter your blood pressure.
Blood Pressure Scale Chart
Have there been any recent changes in your menstrual period? Select any that apply*




When was your last pelvic exam and Pap Smear? *
Was your pap smear normal?*



Have you had a breast exam performed by a clinician in the last 2 years?*


If you are over 40, have you had a mammogram in the last 2 years?*


Have you had any sexually transmitted infections?*


Have you ever experienced a migraine headache with an aura?*


Do you have, or have you had any of the following?*








Have you had any of these conditions relating to blood clots?*




Have you had any hospitalizations or surgeries?*


Do you currently smoke tobacco?*



You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor? Please doublecheck the address,to ensurethat it is accurate.*


Finally, is there anything else we should know? *


We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Date : 07/07/2020

Note: Your medical information will not be saved until you click on the SUBMIT button.