Reschedule / Change An Appointment

Today's Date

Patient's Full Name*

First Last

Patient's Birthdate*

Preferred Method of Contact*

Phone
Email

Patient's Mobile Phone Number*

Patient's Email Address*

Are you comfortable speaking with our staff in English?*

Yes
No

Which language(s) would you prefer to speak?

(Members of our staff can speak Spanish, Hindi and Nepali. We may ask you to provide an adult translator on the phone if we cannot accommodate your language.)

Select your appointment type*

ABORTION CARE (includes options counseling)
GYNECOLOGY (non-pregnant patient only)

Gynecological Care

Which date is your appointment CURRENTLY scheduled for?*

Do you want to reschedule...*

to a different day?
to a different time on the same day?
I need to cancel my appointment.

Select your preferred day to reschedule your appointment:

Abortion Care

Which appointment are you looking to reschedule?*

Telehealth
In-Person
Both Telehealth and In-Person

Which date is your Telehealth appointment CURRENTLY scheduled for?*

Do you want to reschedule your Telehealth appointment...*

to a different day?
to a different time on the same day?
I need to cancel my Telehealth appointment.

Select your preferred day for your Telehealth appointment:

Which date is your In-Person appointment CURRENTLY scheduled for?*

Do you want to reschedule your In-Person appointment...*

to a different day?
to a different time on the same day?
I need to cancel my in-person appointment.

Type of Abortion Care

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To A Different Day

Select your preferred day to reschedule your In-Person appointment

Approximately how many weeks has it been since your last menstrual period?

You can calculate this by using our Pregnancy Calculator. (Opens in a new window)

Select your preferred day to reschedule your In-Person appointment

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Everyone

Additional Comments

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PLEASE READ AND ACKNOWLEDGE THE FOLLOWING:*

I acknowledge that I am submitting a request to change my scheduled appointment. This is not a confirmation that your original appointment time has been canceled or rescheduled. A member of our staff will contact you to complete and confirm rescheduling.

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Reschedule An Appointment

Gynecological Care

Abortion Care

To A Different Day

Everyone

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