Financial Aid Abortion Intake Form Email Address Name Date of Birth When was your last period? How much can you pay towards your abortion? Did you take a pregnancy test? Did you take a pregnancy test? Yes No What was the result of your pregnancy test? What was the result of your pregnancy test? Positive Negative Are you ordering the pills for future use, just in case? Are you ordering the pills for future use, just in case? Yes No Did you have an ultrasound? Did you have an ultrasound? Yes No If yes, can you please enter the date of the ultrasound and how many weeks you were on that date? Are you ordering the pills for future use, just in case? Are you ordering the pills for future use, just in case? Yes No Do you have a period every month? Do you have a period every month? Yes No Do you have someone who can help you during the abortion process? Do you have someone who can help you during the abortion process? Yes No Is someone pushing you to have an abortion or making you afraid to continue the pregnancy? Is someone pushing you to have an abortion or making you afraid to continue the pregnancy? Yes No Do you have an STI (sexually transmitted infection) like gonorrhea, chlamydia, trichomonas or syphilis? Do you have an STI (sexually transmitted infection) like gonorrhea, chlamydia, trichomonas or syphilis? Yes No Do you have any of the following illnesses: an allergy to misoprostol or mifepristone or another prostoglandin; chronic adrenal failure; hemorrhagic disorder (bleeding disease); or inherited porphyrias? Do you have any of the following illnesses: an allergy to misoprostol or mifepristone or another prostoglandin; chronic adrenal failure; hemorrhagic disorder (bleeding disease); or inherited porphyrias? Yes No Do you have any medical problems (involving your lungs, heart, kidneys, liver, thyroid) or mental health diagnoses that Dr. Kaul should know about? Do you have any medical problems (involving your lungs, heart, kidneys, liver, thyroid) or mental health diagnoses that Dr. Kaul should know about? Yes No If so, what are they? Are you taking any medicines? Are you taking any medicines? Yes No If yes, what are they? Name to Ship To Address Line Town/City State Zip Submit
