Book an Appointment for Birth Control

How can we help?

To continue, please fill in or correct the fields marked with red text.

If you need help, call support at 1 (855) 632-6940

What do you want to get out of today's visit?

Tell us a little more about you

What was your last blood pressure reading? You can find this information from a recent medical visit or by taking your blood pressure at a local pharmacy or grocery store. If you're not sure, you can leave this blank.

Do any of the following situations apply to you? If so, select all that apply.

*Hormonal birth control may not be appropriate for patients in certain situations or who have certain medical issues.

I am currently pregnant

Deep venous thrombosis

HIV

History of pulmonary embolism

Have cancer, had cancer, or being tested for cancer now

Had an allergic reaction to birth control medicines before

Systemic lupus erythematosus (SLE) with positive or unknown anti-phospholipid antibodies

Positive or unknown anti-phospholipid antibodies

Surgery or medical condition that affects ability to absorb food or medicine properly, such as gastric bypass or a shortened intestine

Liver problems or history of liver problems

Stroke

None apply

Do any of these risk factors apply to you? If so, select all that apply.

*It's not always appropriate to take combination (estrogen based) hormonal birth control, as there are increased risks of major side effects, including blood clots or stroke.

Smoke cigarettes, e-cigarettes, or use other tobacco products

Given birth in the last 6 weeks

Breastfeeding

Abnormal vaginal bleeding different from my usual period

Periods have become more frequent or heavier than my usual period

Gallbladder problems and still have my gallbladder

Get blood clots, or my family members get blood clots such as deep venous thrombosis (DVT) or pulmonary embolism (PE)

Conditions that thicken the blood (coagulopathy)

Unable to move for long periods of time, such as wheelchair-bound or in recovery after major surgery

Ulcerative colitis or Crohn's disease

Organ transplant

None apply

Do you have high blood pressure, high cholesterol, diabetes, vascular disease, and/or heart problems (including heart attack and heart valve problems) which make it unsafe to take combination birth control?

YesNo

Have you been diagnosed with migraine headaches?

*Certain migraine headaches can increase your risk of stroke and death with hormonal birth control.

YesNo

Over the past 2 weeks, how often have you had symptoms of depression (feeling down or having little interest in doing things) or anxiety (feeling nervous or worrying too much)?

Let's find the right treatment for you

Have you had a pap smear test in the past three years?

Is there anything else related to treatment that you'd like to ask or discuss with your medical provider?

Would you like to share anything else with your provider through an upload?

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