1. Request An Appointment
2. Complete Patient Intake Forms

 

Have you requested an appointment yet? If not, please click here to request an appointment before continuing with the patient intake 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’ll be providing us this information in the following order:

  1. Contact information: We request information to be in touch with you — as well as emergency contact information if needed.
  2. 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.
  3. Medical History: Please complete this as thoroughly as possible. You will have an opportunity to review it with one of our health educators prior to your appointment.
  4. Demographic Information:  To comply with Virginia state law, our Center is required to collect demographic information about the abortioncare 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.
  5. 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.
  6. HIPAA Privacy Notice:  We present a summary of our privacy practices in relation to your care at our Center. We require that you acknowledge this privacy policy and that we have given you the option to receive a printed copy at the time of your appointment.
  7. Insurance information and Consent: If you are using insurance we require that you acknowledge that you have received and understand our insurance policy.

Please note that you will be receiving these forms for signature at your appointment.  We will have them ready for your review and signature during your appointment.

I’m ready to begin!

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