Request An Appointment abortion clinic Falls Church Healthcare Center in VA

Request An Appointment at Falls Church Healthcare Center

To request an appointment please complete the secured online form below.
Once you’ve submitted your request, you will need to complete the Patient Forms.

Please Note: Filling out this form does not guarantee an appointment. Staff will be in touch to confirm your appointment date and time. If you have any questions, please call us at 703-532-2500.

"*" indicates required fields

This field is hidden when viewing the form

Today's Date

Patient's Full Name*

First Last

Pronunciation

(optional)

Patient's Birthdate*

Patient's Age*

Please enter a number from 0 to 99.

First Day of Last Normal Period*

Preferred Method of Contact*

Phone

Patient's Mobile Phone Number*

Confirm Phone Number*

Home Address (we will never send anything unless requested).*

Street Address Address Line 2 City State ZIP Code

Patient's Email Address*

Enter Email Confirm Email

Are you comfortable speaking with our staff in English?*

Yes

What is your preferred language?

Select your appointment type*

ABORTION CARE (medication, procedural)

GYNECOLOGICAL SERVICES (LARC insertion, contraception options)

Select your appointment type*

ABORTION CARE (medication, procedural)

GYNECOLOGY (office visits, exams, contraception)

OPTIONS COUNSELING (pregnancy, abortion, contraception)

Please Indicate Your Payment Method (NOTE: MEDICAID WILL NOT COVER ABORTIONS)*

Private Pay

Insurance

[reblex id='5573']

Who is the insurance policyholder?*

Policyholder Name*

First Last

Policyholder Date of Birth*

Insurance Provider*

Policy / Member ID #*

Group #*

Provider Benefits / Customer Service Phone Number (Located on back of card)*

Use this field to upload a copy or picture of your insurance card (front & back).

Drop files here or

Max. file size: 2 GB, Max. files: 2.

Will you need financial assistance?

Yes

Gynecological Care

Plase be aware that FCHC will be closed on Tuesday, July 4. We will not be providing Telehealth or in-person appointments on that day.

This field is hidden when viewing the form

What type of appointment are you making?*

If "other" gynecological visit, please describe.

Which type of contraception are you interested in?*

Contraception - Other (Please Specify)

Select your preferred day for your gynological careappointment*

Select your preferred day for your Nexplanon appointment*

Select your preferred day for your Depo Provera appointment*

Patient Notes & Medical Conditions

Gynecological Care (Beta)

(B) Select your preferred day for your gynecological care appointment*

(B) What type of appointment are you making?*

(B) If "other" gynecological visit, please describe.

(B) Which type of contraception are you interested in?*

(B) Contraception - Other (Please Specify)

Options Counseling (Beta)

(B) Which type of Counseling are you interested in?

(B) Select Day for your Options Counseling Appointment:*

Abortion Care

Plase be aware that FCHC will be closed on Tuesday, July 4. We will not be providing Telehealth or in-person appointments on that day.

Type of Abortion Care*

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

You can calculate this by using our Pregnancy Calculator in the footer of the website.

Select your preferred day for 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 for your in-person appointment*

Appointments will take 2.5 to 3 hours.

Select your preferred day for your in-person appointment*

Appointments will take 3-4 hours.

Select your preferred day for your in-person appointment*

This field is hidden when viewing the form

Telehealth

[text-blocks id="3351"]

For more information you can visit our Telehealth page here.

Select your preferred day for your TeleHealth appointment*

Preferred Date of Telehealth Appointment?

Abortion Care (Beta)

(B) Type of Abortion Care*

(B) Approximately how many weeks has it been since your last menstrual period?*

You can calculate this by using our Pregnancy Calculator in the footer.

(B) (9) Select your preferred day for your in-person appointment*

Appointments will take 1.5 - 2 hours on weekdays; up to 3 hours on Saturdays.

(B) (11) Select your preferred day for your in-person appointment*

Appointments will take 1.5 - 2 hours on weekdays; up to 3 hours on Saturdays.

This field is hidden when viewing the form

Patient Notes

Patient Notes & Medical Conditions

This field is hidden when viewing the form

Section Break

How did you hear about us?*

Other (Please Specify)

SMS/Text Message Notification

FCHC (through its secure vendor texting service) can contact you by SMS text message. Texting may include appointment reminders and other care-related messages. Your phone number will never be released to outside parties. To opt-out of SMS text messages I may reply STOP at any time or provide written notice to FCHC.

Acknowledge SMS/Text Message Notification*

I acknowledge and understand that I can OPT OUT of SMS text messaging by replying STOP at any time or by providing written notice to FCHC.

Appointment Cancellation Policy

[reblex id='4519']

Appointment Cancellation Policy*

I have read and understand FCHC's appointment cancellation policy.

900 South Washington Street, Suite 300, Falls Church, VA 22046

(703) 532-2500

Request An Appointment at Falls Church Healthcare Center

Gynecological Care

Gynecological Care (Beta)

Options Counseling (Beta)

Abortion Care

Telehealth

Abortion Care (Beta)

Patient Notes

Section Break

SMS/Text Message Notification

Appointment Cancellation Policy