1. Request An Appointment
2. Complete Patient Information Forms
|Have you requested an appointment yet? If not, please click here to request an appointment before continuing with the patient information forms.|
This process will take you through several forms to complete as well as information to read and view. We recommend that you reserve 30 minutes to complete the process. You will have an opportunity to review all of these forms and information with a patient educator.
There is an option to save your progress and continue at a later time. If you choose this, you will receive an email with a link to continue. Please continue in the same browser you used to begin the forms. You may receive errors if you continue in a different browser.
You’ll be providing us this information in the following order:
- Contact information: We request information to be in touch with you — as well as emergency contact information if needed.
- (for abortion patients only) Information about abortion types: We would like you to review this information carefully. It will provide an overview of the different abortion procedures, their strengths and their challenges. You’ll be asked to acknowledge that you have reviewed and understand this material. While you may have a preference of type of abortion, please remember that the decision will be one made by you upon consultation with the medical staff at FCHC to ensure safety and health.
- Medical History: Please complete this as thoroughly as possible. You will have an opportunity to review it with one of our patient educators prior to your appointment.
- (for abortion patients only) Demographic Information: To comply with Virginia state law, our Center is required to collect demographic information about the abortion care patients we see. The information in this box is submitted to the Division of Vital records, Virginia Department of Health. We submit no identifying information along with this.
- (for abortion patients only) Benefits, Alternatives and Risks of Abortion: We ask that you read this document and acknowledge receipt. You will also have an opportunity to download this information.
- (for abortion patients only) Abortion consent form: We require that you read through this and acknowledge that you have read and understand and agree to the terms set forth. You will also have an opportunity to download this form.
- (for procedural abortion patients only) Anesthesia and Sedation Consent Form: If you are considering a procedural abortion, we ask that you review this form and acknowledge receipt. You will sign this form at your in-person appointment.
- (for abortion patients only) Abortion Aftercare Instructions: Please read the appropriate instructions for the type of abortion you’re selecting.
- Insurance information and Consent: If you are using insurance we require that you acknowledge that you have received and understand our insurance policy.
- E-Signature and Date: In order to expedite registration at your in-person appointment, we provide the opportunity for you to electronically sign these forms ahead of time. You will have an opportunity to review these forms and your signature at your in-person appointment. E-signing these forms today is optional.
Again, please note that you will be receiving these forms for review at your appointment.
** NOTE: You should receive a confirmation email from woṃeṇfirst@fallschurchhealthcare.com after you successfully submit your forms. If you do not receive the confirmation email, please check your SPAM folder, and if you still don’t see it please reach out to us via phone (703-532-2500) or the contact form on our website.