CSA Request Form

Welcome to Community Supported Abortion, by We Take Care of Us

Request Form

Para continuar en español, ajuste el idioma en la esquina superior derecha.

Complete this form to request medication by mail.
(mifepristone and misoprostol, or shortened to 'mife' and 'miso')

This form should take about 5 - 7 minutes to complete.

How it works:

First:
We'll ask questions about your medical history to check that mife and miso are safe for you. You'll find out immediately if you are approved to receive our care.

Next:
If you are approved and you wish to continue, we will:
- gather your name, contact info and shipping address
- get your consent to receive care from our team
- explain our pay-what-you-can pricing so you can select a payment amount
- process your payment
All information you provide is completely confidential.
Photo ID is NOT required

Once payment is complete, your order will ship within 1 - 2 business days.

How much it costs:

We use a pay-what-you-can pricing model. The full cost of care is $300. But, we understand that everyone's situation is different. We offer a range of price options below and above the full rate to account for these differences.

Once your safety check is approved and you provide your shipping address, you will see a detailed description of your pay-what-you-can price options. We ask that you honestly consider your ability to pay and select a price that fits your situation.

We provide:

Abortion & miscarriage care
Select this option if you are pregnant now, confirmed by a positive pregnancy test.

Menstrual regulation
Select this option if you think might be pregnant, but you prefer not to take a test.

Abortion medication in advance
Select this option if you are not pregnant now, but want to be prepared just in case.
What kind of care are you requesting?*

Abortion or Miscarriage (I am pregnant now, I have a positive pregnancy test)Menstrual regulation (I think I might be pregnant, I prefer not to take a test)Abortion medication in advance (I am not pregnant, I want medication for the future)

Date

MonthDayYear
Date
Safety check

These questions help us check that mifepristone and misoprostol are safe for you
Are you requesting care for yourself and providing your own medical information?*

yesno

This request form must be completed by the person who plans to take the medication.

If you are here to help someone in your life who needs care - thank you! Please encourage them to visit our website and personally complete a request here:

Period Restoration disclosure

There are instances inwhich the cause of a missed period is unknown. If you missed a period and do not want to take a pregnancy test, mifepristone and misoprostol could help restore your menstrual cycle. However, there is no guarantee that taking the medication will work to bring on a period.

The medication will not cause any harm if you are not pregnant.

If no bleeding occurs after taking the medication, contact your midwife or your primary care provider to investigate other possible causes of your missed period.
I have read this information and I understand:*

Pills in Advance disclosure

Mifepristone and misoprostol can be stored in a cool, dry place and maintain their effectiveness for up to 2 years.

We will be available, should you decide to use the medication in the future. We can help you determine how many weeks pregnant you are, review any changes to your medical history to confirm that mife and miso are still safe for you, explain how to use the medication and offer support.

Please contact Community Supported Abortion / We Take Care of Us when you plan to take the medication.
I have read this information and I understand:*

Have you had an ultrasound during this pregnancy?*

yesno
Do you know the date on which your ultrasound was performed and the estimated gestational weeks / days reported on the ultrasound?*

yesno
Date ultrasound was performed*

MonthDayYear
Date
Gestational age reported *
weeks
.*
days
current GA
cut off by US

We prescribe mifepristone and misoprostol up to 12 weeks and 0 days of pregnancy.
(so that misoprostol can be taken before 13 weeks, accounting for shipping time)

Your current pregnancy dating is:
weeks
days
But don't worry. You can still have an abortion.

To find abortion providers and other resources for your stage of pregnancy, consider visiting:

ineedana.com (for medication abortion and/or clinic-based care)

plancpills.org (for medication abortion via community networks)

abortionfunds.org (for financial assistance and practical support)

Since you do not have an ultrasound (or you don't have access to your ultrasound report) we need to ask some questions about your period.
Does your period come every month, about when you expect it?*

YesNo
Did your last period start about when you expected it?*

YesNo
Was your last period the usual number of days and amount of bleeding?*

YesNo
Do you know the date on which your last period started (within one week)?*

YesNo

There are some situations that could make it harder to determine your pregnancy dating based on your last period. These include:

- you have irregular periods (you sometimes go whole months without a period)
- you don't know the date of your last period
- your last period was abnormal (lighter or shorter than usual)
- you recently gave birth, had a miscarriage or an abortion
- you are breastfeeding around the clock
- you were taking hormonal birth control when you got pregnant

If one of these situations is true for you, and you are unsure how far along you are, please have an ultrasound before completing this form.

If you have questions about why we are requesting an ultrasound, or if you are certain you are less than 12 weeks and 0 days based on other criteria, contact us via our inquiry form.

Good news! We can use your last period to estimate your pregnancy dating.
What was the first day of your last menstrual period?*

MonthDayYear
Based on your last period date, your pregnancy is:
weeks
days
days difference
cut off by LMP
Weeks US & LMP
Days US & LMP

We prescribe mifepristone and misoprostol up to 12 weeks and 0 days of pregnancy.
(so that misoprostol can be taken before 13 weeks, accounting for shipping time)

Your current pregnancy dating is:
weeks
days
But don't worry. You can still have an abortion.

To find abortion providers and other resources for your stage of pregnancy, consider visiting:

ineedana.com (for pills and/or clinic-based care)

plancpills.org (for pills via community networks)

abortionfunds.org (for financial assistance and practical support)

Do any of these conditions or situations apply to you?*

I have had a tubal ligationI have had surgery involving my uterine tubes or other pelvic organsI have had gonorrhea or chlamydia infection, or pelvic inflammatory diseaseI have had an ectopic pregnancy in the pastI currently have an intrauterine device (IUD) in placeI have had severe, one-sided pelvic pain in the weeks since my last periodNone of these apply to me

Do any of these conditions or situations apply to you?*

I have had a tubal ligationI have had surgery involving my uterine tubes or other pelvic organsI have had gonorrhea or chlamydia infection, or pelvic inflammatory diseaseI have had an ectopic pregnancy in the pastI currently have an intrauterine device (IUD) in placeNone of these apply to me

You have at least one risk factor for ectopic pregnancy.
If you have not yet had an ultrasound, consider having an one to confirm pregnancy location before taking mifepristone and misoprostol.

If you prefer to continue without an ultrasound, please read the information below and confirm that you understand:

Ectopic refers to a pregnancy that implants outside the uterus, often in one of the uterine tubes. The risk of ectopic pregnancy is low. However, it may be more likely than usual given your risk factors.

Mifepristone and misoprostol are not effective if pregnancy is outside the uterus. Other treatments are needed to end an ectopic pregnancy. If untreated, an ectopic pregnancy could burst and cause dangerous bleeding in the abdomen.

Signs of a ruptured ectopic pregnancy include severe abdominal pain (often on one side), dizziness, and feeling weak or fainting. If you have any of these signs, you should go to the nearest emergency room immediately.

Not bleeding after taking mifepristone and misoprostol may also be a sign of ectopic pregnancy. If you do not bleed after taking misoprostol, contact your midwife or your primary care provider. An ultrasound may be needed.
You have at least one risk factor for ectopic pregnancy.
If you become pregnant and decide to use abortion pills in the future, consider having an ultrasound first to confirm the pregnancy location.

If you decide to use abortion pills without an ultrasound, please keep in mind:

Ectopic refers to a pregnancy that implants outside the uterus, often in one of the uterine tubes. The risk of ectopic pregnancy is low. However, it may be more likely than usual given your risk factors.

Mifepristone and misoprostol are not effective if pregnancy is outside the uterus. Other treatments are needed to end an ectopic pregnancy. If untreated, an ectopic pregnancy could burst and cause dangerous bleeding in the abdomen.

Signs of a ruptured ectopic pregnancy include severe abdominal pain (often on one side), dizziness, and feeling weak or fainting. If you have any of these signs, you should go to the nearest emergency room immediately.

Not bleeding after taking mifepristone and misoprostol may also be a sign of ectopic pregnancy. If you do not bleed after taking misoprostol, contact your midwife or your primary care provider. An ultrasound may be needed.
I have read this information and I understand:*

You have an IUD.

Please consider removing the IUD before taking misoprostol. There is a possible risk that the IUD could damage your uterus if it is still inside when you take the medication.

You can have the IUD removed by your primary care provider or OBGyn provider, if you have one.

If seeing a clinician to have your IUD removed is not an option for you, you can find information about removing the IUD yourself here:

IUD self-removal
I have read this information and I understand:*

Do any of these conditions or situations apply to you?*

I have a bleeding disorderI currently take a blood thinning medication (such as Heparin, Lovenox, Warfarin or Eliquis)I currently have severe anemia, requiring a blood transfusion within the past yearNone of these apply to me

You are at risk of bleeding too much during a medication abortion. Procedural abortion may be a safer option for you.

If you have questions about your eligibility determination, you may contact us through our Inquiry Form.

To find abortion providers and resources to assist you in accessing procedural abortion, consider visiting:

ineedana.com

abortionfunds.org

Do any of these conditions or situations apply to you?*

I have inherited porphyriaI have chronic adrenal failureI currently take a long-term, systemic corticosteroid medication (does not include topical creams, ointments, inhalers or testosterone)None of these apply to me

Procedural abortion may be a safer option for you.

If you have questions about your eligibility determination, you may contact us through our Inquiry Form.

To find abortion providers and resources to assist you in accessing procedural abortion, consider visiting:

ineedana.com

abortionfunds.org

Do any of these conditions or situations apply to you?*

I have had a previous allergic reaction to mifepristoneI have had a previous allergic reaction to misoprostolI have never had an allergic reaction to either medication

Procedural abortion may be a safer option for you.

If you have questions about your eligibility determination, you may contact us through our Inquiry Form.

To find abortion providers and resources to assist you in accessing procedural abortion, consider visiting:

ineedana.com

abortionfunds.org

Thank you for completing the safety check.
We confirmed that mifepristone and misoprostol are safe for you.

You are approved for care!
What would you like to do next?*

I am ready to provide my personal information and pay to receive care.I want to ask questions before moving forward. Put me in touch with the care team.I am still considering my options. Let me know how to follow up later.

We are happy to answer any questions you may have.
You can submit questions via our Inquiry Form.

It is normal to feel unsure and to need more time to decide.

If you have a current pregnancy, we can process your request through 12 weeks and 0 days. Please return to our website when you are ready to continue.

If you have a question before moving forward, contact us through our Inquiry Form.

For support thinking through your options, consider visiting All Options.

Now we'll collect your personal information so that we can coordinate your care.
First name*
Last name*
Nickname / Preferred name (optional)
only if you want to be called something different than the name above, please!
Pronouns you use

she/her/hershe/him/histhey/them/theirsOther
Date of birth*

MonthDayYear
Date
Date of birth - year first

YearMonthDay
Date
Age

Phone number*
Please enter a valid phone number.
Email*
example@example.com
Preferred language for ongoing messaging with our team*

EnglishSpanish
We will send you a text message inviting you to a secure messaging application called Spruce. After completing your request, all communication about your care will take place in Spruce.

Shipping Address

Please provide the address where you want to receive your prescription. This address does not have to be your residential address and it does not have to match the address on your credit card.

Make sure the address you provide is correct and complete.
Include the apartment, unit or suite number, if applicable.

Double and triple check! Providing an incorrect or incomplete address may lead to shipping delays or additional fees.
Street address*
Apartment or unit #
City*
State*
(acronym only)
Zipcode*
Country
Prescriber
doctor
Carrier HB
Carrier

Personal context and care needs

Optional
Our goals is to provide supportive, accessible, trauma-informed and gender expansive care. Below, please share any information about your personal context or care needs that you would like us to know.

Examples might include:

Do you need accessibility accommodations? Will you have in-person support? Do you have a secure place to stay? Are you experiencing violence or trauma that impacts your care needs? Do you desire frequent text support from our team or do you prefer to be undisturbed? etc.

If you prefer not to share, you may leave this section blank.

Consent to care
Now we'll get your consent to receive care from our team.
Please read these documents carefully and sign to give your consent:
General consent to care via telehealth
Consentimiento general para la atención por telemedicina
I have read this document and I consent: *

Clear
Mifepristone manufacturer/patient agreement
Acuerdo entre el fabricante y la paciente de mifepristonaa
I have read this document and I consent: *

Clear
Date:

You're almost done!
Thank you for providing your personal information and your consent to care.

Next, we will explain our pay-what-you-can pricing options, and ask you to select a payment amount that fits your situation. Then we'll collect your payment.
Should be Empty:

Safety check

Medical History

Personal context and care needs

Consent to care