Have you requested an appointment yet? Please click here to request an appointment before continuing with the patient intake forms.
You will be completing four forms during this process:
1. Demographic Information: To comply with Virginia state law, our Center is required to collect demographic information about the 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.
2. Medical History: Please fill in as much information as you can in this section. You will have an opportunity to review it with one of our health educators during your visit.
3. Ultrasound Consent Form (for abortion care patients): Virginia Code 18.2-76 advises that an ultrasound of the uterus must be performed. Our Center requires that you issue consent for and state personal preferences regarding the ultrasound.
Please note that you will not be signing these forms until you arrive for your appointment. When you submit these forms we will have them ready for review and signature during your appointment.