Medication Request Form

Medication Request Form

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Complete this form to determine your medical eligibility to receive care for medication abortion, miscarriage management or menstrual regulation.

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 you are eligible according to guidelines set by the FDA and World Health Organization. You'll find out immediately if you are eligible for care with one of our affiliated U.S. licensed providers.

Next:
If you are eligible and you wish to continue, we will:

- Collect the following person details:
- Full name
- Contact info (this is where a provider from our team will reach you)
- Shipping address (where your medication will be mailed)
- Request a signature from you consenting to our services
- Provide you with information about our pay-what-you-can pricing model
- Collect and process your payment

All information you provide is confidential.

While each person’s care is different, you can expect your provider to contact you about your care plan within 1-2 business days of completing this form.

How much it costs:

We use a pay-what-you-can pricing model. We understand that everyone's situation is different. We offer a range of price options to account for these differences.

Once your eligibility is approved, you will see a detailed description of your pay-what-you-can price options. We trust that you will 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 and/or an ultrasound.

Menstrual regulation
Select this option if you think might be pregnant and you want to bring your period back.

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?

Date

MonthDayYear
Date
Eligibility Screening

These questions help us check that abortion care via telehealth is appropriate for you.
Are you the individual who is requesting care and who will take any treatment the provider prescribes?

This request form must be completed by the person who is in need of care.

If you are here to help someone in your life who needs care - thank you! Only the person in need of care is eligible to use our website and services. Please encourage that person to visit our website and personally complete the request:

Period Restoration Disclosure

There are instances in which the cause of a missed period is unknown. Mifepristone and misoprostol can be used to restore the menstrual cycle when a missed period due to pregnancy. However, the medication is not intended to restore missed periods when pregnancy is not the cause.

If no bleeding occurs after treatment, we will recommend that you contact your primary care or gyn 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.

A U.S. licensed provider from our team 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 you are still eligible for medication abortion care at the time of need, 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?
Do you know the date on which your ultrasound was performed and the estimated gestational weeks / days reported on the ultrasound?
Date ultrasound was performed

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

We accept new requests for care up to 12 weeks and 0 days of pregnancy.
(so that treatment can be initiated before 13 weeks)

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 regularly every month?
Did you have normal periods that started on time for the 3 months before becoming pregnant?
Was your last period completely normal in color, consistency, amount of flow and number of days of bleeding?
Do you know the date on which your last period started (within one week)?

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, we request that you have an ultrasound before completing this form.

Good news! We can use your last period to estimate your pregnancy dating.
What was the first day of your last normal 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 accept new requests for care up to 12 weeks and 0 days of pregnancy.
(so that treatment can be initiated before 13 weeks)

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?

Do any of these conditions or situations apply to you?

You have at least one risk factor for ectopic pregnancy.
If you have not yet had an ultrasound, consider having one to confirm that your pregnancy is in your uterus 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 factor(s).

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, 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 local OB 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 that the pregnancy is in your uterus.

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 factor(s).

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, 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 local OB provider. An ultrasound may be needed.
I have read this information and I understand:

You have an IUD.

Please consider having an ultrasound to confirm that your pregnancy is inside the uterus before using mifepristone and misoprostol.

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?

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

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?

Procedural abortion may be a safer option for you.

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?

Procedural abortion may be a safer option for you.

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

ineedana.com

abortionfunds.org

Thank you for completing the eligibility check.
We confirmed that you are medically eligible for abortion care via telehealth.

You are eligible for care!

Next steps:
You may provide your personal information and payment to move forward and connect with a U.S. licensed provider. The provider will review your chart and contact you about your plan of care within 1 - 2 business days. If, for some reason, the provider determines that abortion care via telehealth is not the best care plan for your situation your payment will be refunded.
What would you like to do next?

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

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

For decision-making support, 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

Other
Date of birth

MonthDayYear
Date
Date of birth - year first

YearMonthDay
Date
Age

Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred language for ongoing messaging with our team
We will send you a text message inviting you to a secure messaging application called Spruce. After completing your request and logging in to the app, all communication about your care will take place in Spruce.

Shipping Address

Please provide the address where you want to receive any prescribed treatments. 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 patients with supportive, accessible, trauma-informed and gender expansive care. Below, please share any information about your personal context or care needs that may help us provide you with the most effective care.

Examples might include:

Will you have in-person support from a friend, family member or partner?
Do you have the support of a trusted in-person healthcare provider?
Do you have a safe place to stay during your care?
Does your gender identity impact your care needs?
Are you experiencing violence or trauma that impacts your ability to receive care?
Do you desire frequent support from our team via secure messaging?
Or do you prefer to be undisturbed?
Anything else at all that you want our team to know?

If you prefer not to share, you may leave this section blank.
Please share anything you would like our team to know about you and your context:

Consent to care
Now we'll get your consent to receive care from one of our affiliated providers. Please read each section carefully, initial, and sign where indicated to acknowledge your consent to care.
GENERAL CONSENT

I am asking for medical care and treatment from a Healthcare Provider I was connected to through the platform We Take Care of Us (“The Platform”). I agree to accept services which may diagnose a medical condition, and procedures to treat my condition. I understand that these services will be provided to me by a U.S. licensed Certified Nurse Midwife (the “Affiliated Provider”). I understand that Platform staff will help support with non-clinical services. I have not been given any guarantees as to the results of the services I will receive.

I understand that I have a right to discuss my condition and all medical treatments with my Affiliated Provider. I understand that I have a right to refuse any procedure or treatment. I understand that my agreement to accept these services will remain in effect unless I say that I no longer want these services or until my treatment is completed.

I understand that my agreement to accept these services is called a General Consent and that it includes collection of my health history, routine procedure(s) or treatment(s) such as laboratory studies, imaging studies, and administration of medication(s). I further understand that de-identified data collected during the course of my care may be used for educational and research purposes.

I affirm that the information I have provided is accurate to the best of my knowledge. I understand that I am responsible to inform my care providers of any change in my health status or condition.

I understand that I must pay for the cost of these services, whether or not I have insurance. I understand that some of these services may be covered by insurance. I understand that it is my responsibility to verify coverage and to submit the required documentation to my insurer in order to receive reimbursement, if applicable.
CONSENTIMIENTO GENERAL

Solicito atención y tratamiento médico a un proveedor de atención médica con el que fui conectada a través de la plataforma We Take Care of Us (“La Plataforma”). Acepto recibir servicios que puedan diagnosticar una afección médica, así como procedimientos para tratar mi afección. Entiendo que estos servicios me serán proporcionados por una Enfermera Partera Certificada con licencia en los EE. UU. (la “Proveedora Afiliada”). Entiendo que el personal de la Plataforma brindará apoyo mediante servicios no clínicos. No se me ha ofrecido ninguna garantía con respecto a los resultados de los servicios que recibiré.

Entiendo que tengo derecho a conversar sobre mi afección y sobre todos los tratamientos médicos con mi Proveedora Afiliada. Entiendo que tengo derecho a rechazar cualquier procedimiento o tratamiento. Entiendo que mi acuerdo para aceptar estos servicios permanecerá vigente a menos que yo indique que ya no deseo recibirlos, o hasta que mi tratamiento haya concluido.

Entiendo que mi acuerdo para aceptar estos servicios se denomina Consentimiento General y que incluye la recopilación de mi historial de salud, así como procedimientos o tratamientos de rutina, tales como análisis de laboratorio, estudios de imagen y la administración de medicamentos. Asimismo, entiendo que los datos anonimizados recopilados durante el transcurso de mi atención médica podrán ser utilizados con fines educativos y de investigación.

Declaro que la información que he proporcionado es veraz, a mi leal saber y entender. Entiendo que es mi responsabilidad informar a mis proveedores de atención médica sobre cualquier cambio en mi estado de salud o afección.

Entiendo que debo cubrir el costo de estos servicios, independientemente de si cuento o no con un seguro médico. Entiendo que algunos de estos servicios podrían estar cubiertos por mi seguro. Entiendo que es mi responsabilidad verificar la cobertura y presentar la documentación requerida a mi aseguradora para obtener el reembolso correspondiente, si este fuera aplicable.
Initials
Date

MonthDayYear
Date
MEDICATION ABORTION INFORMED CONSENT
CONSENTIMIENTO INFORMADO PARA EL ABORTO CON MEDICAMENTOS
By initialing below, I agree that:

1. I have read and understand the information provided to me about medication abortion.

2. All information I have provided is true and correct, and I acknowledge that my Affiliated Provider and staff have relied on such information.

3. All my questions have been answered to my satisfaction.

4. I understand that I will also have an opportunity to discuss my care plan with my Affiliated Provider and to have all of my questions answered before proceeding with any recommended treatment.

5. I give my consent voluntarily. No one is forcing me to make this decision.

6. I am aware that I may have a copy of this information at my request.
Al firmar con mis iniciales a continuación confirmo que:

1. He leído y comprendido la información que se me ha proporcionado sobre el aborto con medicamentos.

2. Toda la información que he proporcionado es veraz y correcta, y reconozco que mi proveedor afiliado y su personal se han basado en dicha información.

3. Todas mis preguntas han sido respondidas a mi entera satisfacción.

4. Entiendo que también tendré la oportunidad de hablar sobre mi plan de atención con mi proveedor afiliado y de que se respondan todas mis preguntas antes de proceder con cualquier tratamiento recomendado.

5. Doy mi consentimiento voluntariamente. Nadie me obliga a tomar esta decisión.

6. Soy consciente de que puedo obtener una copia de esta información si la solicito.
Initials
Date

MonthDayYear
Date
TELEHEALTH INFORMED CONSENT
CONSENTIMIENTO INFORMADO PARA SERVICIOS DE TELESALUD
By initialing below, I affirm that:

1. I have read the information provided to me and I understand the laws protecting the privacy and confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth at any time.

3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.

5. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform my Affiliated Provider of interactions regarding my care that I may have with other healthcare providers and staff.

7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

8. I have read and understand all of the information presented above. If my Affiliated Provider deems it medically safe and appropriate, I consent to receive services via telehealth.

9. I consent to receive protected health information via email or SMS text messaging, and I understand that messages shared through these communication channels may not be secure in every instance.
Al firmar con mis iniciales a continuación, confirmó que:

1. He leído la información que se me ha proporcionado y entiendo que las leyes que protegen la privacidad y la confidencialidad de la información médica también se aplican a la telemedicina, y que ninguna información obtenida mediante la telemedicina que me identifique será divulgada a investigadores u otras entidades sin mi consentimiento.

2. Entiendo que tengo derecho a negar o retirar mi consentimiento para el uso de la telemedicina en cualquier momento.

3. Entiendo que tengo derecho a inspeccionar toda la información obtenida y registrada durante una interacción de telemedicina, y puedo recibir copias de esta información por una tarifa razonable.

4. Entiendo que puedo tener a mi disposición diversos métodos alternativos de atención médica, y que puedo elegir uno o más de ellos en cualquier momento.

5. Entiendo que la telesalud puede implicar la comunicación electrónica de mi información médica personal a otros profesionales médicos que pueden estar ubicados en otras áreas, incluso fuera del estado.

6. Entiendo que es mi deber informar a mi proveedor afiliado sobre las interacciones relacionadas con mi atención que pueda tener con otros proveedores y personal de atención médica.

7. Entiendo que puedo esperar los beneficios previstos del uso de la telesalud en mi atención, pero que no se pueden garantizar ni asegurar resultados.

8. He leído y comprendo toda la información presentada anteriormente. Si mi proveedor afiliado lo considera médicamente seguro y apropiado, doy mi consentimiento para recibir servicios a través de la telesalud.

9. Doy mi consentimiento para recibir información de salud protegida por correo electrónico o mensajes de texto SMS, y acepto recibirla.
Initials
Date

MonthDayYear
Date
CONSENT TO RELEASE OF MEDICAL RECORDS TO NON-CLINICAL SUPPORT STAFF

I understand that:

During my care, I will be given access to the Spruce application where I can reach my Affiliated Provider or support staff should I need help outside of office hours, 24/7.

I authorize my Affiliated Provider to release my medical records, including any relevant medical history, diagnostic test results, treatment plans, and provider notes, to any cross-covering providers and support staff as necessary for the purpose of continued and coordinated care.

I understand that this information may include sensitive or protected health information relevant to my treatment and care coordination, and it will only be shared with providers and staff directly involved in my care. I acknowledge that this consent is given voluntarily and that I may revoke it in writing at any time, except to the extent that action has already been taken based on this authorization. This consent will remain in effect until such revocation or until I am no longer receiving care with We Take Care of Us.
CONSENTIMIENTO PARA LA DIVULGACIÓN DE REGISTROS MÉDICOS AL PERSONAL DE APOYO NO CLÍNICO

Entiendo que:

Durante mi atención, se me otorgará acceso a la aplicación Spruce, a través de la cual podré comunicarme con mi Proveedor Afiliado o con el personal de apoyo en caso de necesitar ayuda fuera del horario de oficina, las 24 horas del día, los 7 días de la semana.

Autorizo a mi Proveedor Afiliado a divulgar mis registros médicos —incluyendo cualquier historial médico pertinente, resultados de pruebas diagnósticas, planes de tratamiento y notas del proveedor— a cualquier proveedor de cobertura cruzada y al personal de apoyo, según sea necesario, con el fin de garantizar una atención continua y coordinada.

Entiendo que esta información puede incluir datos de salud sensibles o protegidos que sean pertinentes para mi tratamiento y la coordinación de mi atención, y que solo se compartirá con los proveedores y el personal directamente involucrados en mi cuidado. Reconozco que este consentimiento se otorga de manera voluntaria y que puedo revocarlo por escrito en cualquier momento, salvo en la situación en que ya se hayan tomado medidas con base en esta autorización. Este consentimiento permanecerá vigente hasta que se produzca dicha revocación o hasta que deje de recibir atención por parte de We Take Care of Us.
Initials
MonthDayYear
Date
AUTHORIZATION AND FINAL CONSENT

I have read and understand the information provided above regarding: general consent to care, medication abortion, telehealth services, privacy and communications, and research data use. I understand that an Affiliated Provider or support staff is available to answer any questions I may have to my satisfaction before I give my consent.

I hereby authorize We Take Care of Us to provide my requested care services and to connect me with an Affiliated Provider to use telemedicine in the course of my diagnosis and treatment.
AUTORIZACIÓN Y CONSENTIMIENTO FINAL

He leído y comprendo la información proporcionada anteriormente con respecto a: el consentimiento general para la atención, el aborto con medicamentos, los servicios de telesalud, la privacidad y las comunicaciones, y el uso de datos para fines de investigación. Entiendo que hay un Proveedor Afiliado o personal de apoyo disponible para responder, a mi entera satisfacción, cualquier pregunta que pueda tener antes de otorgar mi consentimiento.

Por la presente, autorizo a We Take Care of Us a prestar los servicios de atención que he solicitado y a ponerme en contacto con un Proveedor Afiliado para utilizar la telemedicina en el transcurso de mi diagnóstico y tratamiento.
I also attest that I have had an opportunity to review the Terms of Use and:
Signature
Date

MonthDayYear
Date
Printed name of patient
Mifepristone manufacturer/patient agreement
Acuerdo entre el fabricante y la paciente de mifepristonaa
By Signing Below, I affirm that I have read the manufacturer agreement and I consent:
Signature:
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:

Eligibility Screening

Medical History

Personal context and care needs

Consent to care