Birth Control Survey

Birth Control Online

There are only a few steps to get started.

    Choose your Location

    What is your date of birth?

    How can we help you today?

    Please tell us more about your birth control needs.

    Let’s calculate your BMI. BMI can impact the effectiveness of some birth control methods.

    ft
    in
    lbs
    cm
    kg

    Please enter your BMI Result

    Underweight

    Normal weight

    Over Weight

    Obese

    Have you used birth control before?


    What other type of birth control have you used before?

    Which birth control type would you prefer?

    What are your primary reasons for using birth control?


    Including regulating your periods please describe

    How often do your periods occur?


    Please Describe

    Have you ever been told by a healthcare professional not to take hormones?


    Please Describe

    Do any of the following apply to you? Select all that apply.

    Are you a current smoker?

    Do you have a history of migraines?

    Do you have warning signs or symptoms before the headaches start? Such as tingling, numbness, flashing lights, or blind spots.

    Do you have any gynecologic conditions? Such as polycystic ovary syndrome, endometriosis, spotting in between periods or painful intercourse.

    Please list Conditions

    How much do you smoke per day?

    Have you had surgery in the past 6 weeks or have surgery planned within the next month?

    Do you have any of the following conditions?

    Do you have any drug allergies?

    Please Describe

    Are you currently taking any medications or herbal treatments other than birth control, even if temporarily?

    In order for us to provide you with the best care, please let us know what medications you take.

    Do you have any other diagnosed medical conditions?

    Please list your diagnosed medical conditions.

    Have you had your blood pressure measured in the past 6 months?

    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

    Do you have a preference about a specific birth control medication?

    Please tell us the specific medication you are looking for and why

    Anything else you would like us to know?

    Tell us about any concerns or questions you have for the medical team.

    How would you like to pay?

    upload emirates insurance details (if available)

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    Personal Details

    Title:
    First Name: Last Name:
    Date of Birth:
    Mobile Number: E-mail:

    Address Details

    Google Map: (Please Share your Google Map Link)
    Neighborhood/Area:
    Street Name/No:
    Address Details:

    Insurance & Id Details

    Upload Emirates ID

    Insurance Card Image (Optional)
    Insurance provider:
    Insurance card no:
    Feel free to leave any additional comments here:

    Confirm Request and Agree to Terms