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? 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?

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?

Please write out your street address including apartment number, if applicable, and city, state and zip code where you would like to receive the pills. If this is not an address where you regularly receive mail, please tell us the name of someone who regularly receives mail here so that we can be sure your package will get to you.