The following forms are available to Download and Print before your appointment.
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Please download these forms on white paper and complete in black ink. These forms will become part of your medical record.
Please read the following information carefully to determine which forms you need.
Completed forms should be brought with you to the clinic for your appointment.
If you have not called for an appointment, please do so, BEFORE coming in.
We make every attempt to see Emergency Contraception (EC) clients within 120 hours of calling, however
if you simply show up, it is possible you will have to reschedule to see a counselor at a later date.
→If you are in need of Emergency Contraception (the morning-after pill) and have NOT gotten EC’s from one of our family planning clinics in the past year, please download the following forms:
* EC Consent Form (Read and sign only)
* EC Intake Form (Complete front page only) →If you are in need of Emergency Contraception (the morning-after pill) and HAVE gotten EC’s from one of our family planning clinics in the past year, please download the following form: * EC Visit Form (Complete top portion only).
* * * * * * * * * *
Completed forms should be returned to the clinic at the time of your scheduled visit.
If you have not yet scheduled an appointment, please do so, as we are not able to see clients on a walk-in basis.
(Click on to the clinic site closest to you for the telephone number to call, hours of operation and directions) →If you need an exam, or wish to start birth control (which requires an exam) please download the following forms:
* Demographics (complete to dotted line only)
* General Consent (read and sign)
* Initial Medical History Form for Females
* Initial Medical History Form for Males
* If under the age of 18: Minor Preamble (Read only)
→You will also need to fill out a Consent form for the specific birth control method you desire: * Consent CHCM (pill, patch, ring)
* Consent DEPO
* Consent Diaphragm
* Consent Cervical Cap
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* How to Use Combined Oral Contraceptive Pills
* How to Use Combined Contraceptive Vaginal Ring
* How to Use Combined Contraceptive Patch
* How to Use Emergency Contraceptive Pills
* How to Use Progestin-Only Pills
* Combined Oral Contraceptive Pill Information
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