User Info

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Mobile Number

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Email Address

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Additional Personal Information

Any allergies to Medications?

If yes, list them here:

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Date of Birth

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Background Information

Do you think you might be pregnant now?



Have you ever taken birth control pills, or used a birth control patch, ring, or injection?


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

Did you ever experience a bad reaction to using hormonal birth control?

If yes, what kind of reaction occurred?

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Are you currently using any method of birth control including pills, or a birth control patch, ring or shot/injection? If yes, which one do you use? Yes No

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Medical History