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 determine your medical eligibility to receive medication by mail for 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 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 review your care plan and write your prescription within 1-2 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 and you provide your shipping address, 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.
Abortion or Miscarriage medicationMenstrual regulation medicationAbortion medication in advance

Date

MonthDayYear
Date
Eligibility Screening

These questions help us check that mifepristone and misoprostol are safe for you
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! 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. 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 is safe to take even if one is not pregnant.

If no bleeding occurs after taking the medication, we will recommend that you contact your primary care or gyn provider to investigate other possible causes of your missed period.

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.

yesno
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.
YesNo
YesNo
YesNo
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, 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 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)

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

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 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.

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 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.

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

ineedana.com

abortionfunds.org

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.

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

ineedana.com

abortionfunds.org

I have taken mifepristone and I had an allergic reactionI have taken misoprostol and I had an allergic reactionI have no history of allergic reaction to mifepristone and/or misoprostol

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 to use mifepristone and misoprostol.

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 write your prescription. If, for some reason, the provider determines that taking mifepristone and misoprostol is not the best care plan for your situation your payment will be refunded.
I am ready to provide my personal information and payment to apply for care.I am still considering my options. I will follow up later.

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!
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.Format: (000) 000-0000.
Email*
example@example.com
EnglishSpanish
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 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 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 our U.S. licensed providers.
Please read these documents carefully and sign to give your consent:
General consent to care with mifepristone and misoprostol via telehealth
Consentimiento general para la atención por telemedicina
I have read this document and I freely provide my consent to care*

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:

Eligibility Screening

Medical History

Personal context and care needs

Consent to care