—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
Starting birth control for the first timeRefilling birth controlRestarting birth controlOthers
Please tell us more about your birth control needs.
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Please enter your BMI Result
What other type of birth control have you used before?
Prevent pregnancySkip periodsReduce crampsDoctor’s diagnoses (polycystic ovary syndrome, etc)Improve skinOthers
Including regulating your periods please describe
1-2 weeks3-4 weeks5-6 weeksFew monthsIrregularlyOther
—Please choose an option—NoneI am pregnantI have delivered a baby in the last 6 weeksI am currently breastfeedingI could be possibly pregnant or had recent unprotected intercourse
Do you have a history of migraines? YesNo
Do you have warning signs or symptoms before the headaches start? Such as tingling, numbness, flashing lights, or blind spots.YesNo
Do you have any gynecologic conditions? Such as polycystic ovary syndrome, endometriosis, spotting in between periods or painful intercourse.YesNo
Please list Conditions
How much do you smoke per day?5 cigarettes5-10 cigarettes11-15 cigarettes15+ cigarettes
Bariatric or stomach reduction surgeryCrohn’s disease or ulcerative colitisClotting disorder or known personal or family history of blood clotsCystic fibrosisDiabetes for greater than 20 years or with complicationsFamily history of breast cancerHepatitis C, gallbladder disease, or liver conditionsHigh blood pressureHigh cholesterolHistory of heart attack or stroke or other heart conditionsLupusPersonal history of cancerPersonal history of depressionRheumatoid arthritis
In order for us to provide you with the best care, please let us know what medications you take.
Please list your diagnosed medical conditions.
Your prescription won’t be processed until you tell us your blood pressure numbers. You can have your blood pressure checked at most pharmacies or use a home blood pressure cuff. If you aren’t sure when you last had it taken, call your doctor’s office and ask if it was within six months and what the numbers were.
What was your systolic (top) number?
Normal or low: 129 or less High: 130 and up What was your diastolic (bottom) number? Normal or low: 89 or less
High: 90 and up
Please tell us the specific medication you are looking for and why
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsurance
First Name: Last Name:
Date of Birth:
Mobile Number: E-mail:
Google Map: (Please Share your Google Map Link)
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Insurance Card Image (Optional)
Insurance card no:
Feel free to leave any additional comments here:
After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.