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ABORTION PILL
PROCEDURAL ABORTION
Awake (through 12 weeks)
Asleep (through 15 weeks)
SERVICES
Gynecological Care
Other Care
Abortion Options Counseling
Doula
FEES
Cost / Insurance
Financial Assistance
ABOUT
Who We Are
Tour Our Center
Video Resources
Patient Comments
DONATE
FAQs
General FAQs
Info for Patients Under 18
Telehealth
PATIENT CENTER
Request An Appointment
Reschedule / Change An Appointment
Patient Information Forms
Provide 2-Week Follow-Up
Abortion Aftercare
Medical Records Release
Pregnancy Calculator
CONTACT US
Español
ABORTION PILL
PROCEDURAL ABORTION
Awake (through 12 weeks)
Asleep (through 15 weeks)
SERVICES
Gynecological Care
Other Care
Abortion Options Counseling
Doula
FEES
Cost / Insurance
Financial Assistance
ABOUT
Who We Are
Tour Our Center
Video Resources
Patient Comments
DONATE
FAQs
General FAQs
Info for Patients Under 18
Telehealth
PATIENT CENTER
Request An Appointment
Reschedule / Change An Appointment
Patient Information Forms
Provide 2-Week Follow-Up
Abortion Aftercare
Medical Records Release
Pregnancy Calculator
CONTACT US
Español
Patient Follow-Up
Online Follow-Up
Name
*
First
Last
Hidden
Today's Date
MM slash DD slash YYYY
Date of Birth
*
Month
Day
Year
Phone
*
May we leave a message?
*
Yes
No
Email
Prefered Method of Contact:
*
Phone
Email
Follow-Up Evaluation
Date of Procedure:
*
MM slash DD slash YYYY
Tell us about your recovery:
What are the results of your at-home pregnancy test?
*
Not Pregnant
Pregnant
How are you feeling now?
*
Do you have any concerns?
*
Tell us about your bleeding:
Number of days of bleeding
*
Color of Bleeding
*
Red
Pink
Brown
Mixture of All
Are you still bleeding?
*
Yes
Just spotting
No
Did you have clots?
*
Yes
No
How often did you have clots?
*
Size of clots
*
Additional Questions:
Did you have any other vaginal discharge?
*
Yes
No
Was there odor?
*
Yes
No
Please describe further if needed:
Do you still have nausea?
*
Yes
No
Do you still have breast tenderness?
*
Yes
No
Did you start any hormonal birth control?
*
Yes
No
When did you start hormonal birth control?
*
MM slash DD slash YYYY
I would like a prescription for birth control
I would like a prescription for birth control
Name of Pharmacy
Pharmacy Phone number
When was your last Well Woman Exam / Pap Smear test?
Can we help you with any GYN services or concerns?
*
Yes
No
How can we help you?
*
Have you had sexual intercourse since your procedure?
*
Yes
No
Was protection used?
*
Yes
No
Would you like us to call you to answer any further questions you may have?
*
Yes
No
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