Medication Abortion Booking Form

Before filling out the booking form:

Make sure you have read about Medication Abortions here.
Make sure you have had a positive pregnancy test from either an at home pregnancy test or from a health care provider
We will also need the first date of your last period (if you know it)
You will need to be 10 weeks or less from the first day of your last period on the day on the day that we are able to see you
Referral from a doctor is welcome but not required. If you would like we can send a letter to your doctor about your visit.
Please make sure to have your BC medical number (PHN) with you if you have one.

We usually book appointments within a few days, so we will do our best to respond promptly.

Make sure you can spend 5 to 10 minutes on the phone when booking your appointment or when we call you back. We will be asking you some personal questions and giving you some more information so you may need some privacy for this call.
If you require an interpreter, please let us know and we can assist with telephone interpretation services.

We will try to contact you at least 3 times throughout the next business day. ( Mon – Fri )
If we do not reach you please try and call us at: Telephone hours: 9:30 – 12:00 and 1:30 – 4:30, Monday – Friday. Call 604-709-5611

Once you are ready you can call us or fill out the call request form :

Medication Abortion

You will have an information session either with one of our counsellors or by watching an information video – see more setail below.

You will come into the clinic for about 1 – 1.5 hours. We will collect a urine sample, you will see our physician who will do a vaginal ultrasound, go over your history and give you a prescription to take to the pharmacy.

You will take pills and have the bleeding at home. We will give you pain medication to take as needed.

Counselling Options

Counsellor – We have counsellors available to speak with you either by phone or video to check in with you to see how you are feeling and provide support. They will also explain the medications, discuss contraception and give you any resources you may want as you go through this process.

Video Information Session – We have a detailed video available for viewing that explains how to take the medications, what to expect as you go through the process and reviews the contraception that is available to you after the procedure. You will have the opportunity to ask questions when you come in if you need any further information.

Aspiration Abortion

We do not provide Aspiration (surgical) abortion at Willow. You will go to a different clinic that does this procedure. Your appointment will be about 2 – 3 hours. A nurse will insert an intravenous and give you some medications. The doctor does the abortion by numbing the cervix with local anesthetic and then opening the cervix a little bit to insert a small tube. They then remove the pregnancy with gentle suction. It usually takes 7 or 8 minutes.

For Aspiration Abortions please contact

Everywoman’s Health Center – 604-322-6692 https://everywomanshealthcentre.ca

CARE Program BC Women’s Hospital – 604-875-2022 http://www.bcwomens.ca/our-services/gynecology/abortion-contraception

Elizabet Bagshaw Clinic – 604-736-7878 https://bagshawclinic.ca/

Please enable JavaScript in your browser to complete this form.

I am looking for a medication abortion.

Yes or No?

Name:

Type your name above

Personal Health Number (PHN) or other province health card number or type 'no health care card':

Type your PHN above

Phone number:

Please enter the number with hyphens ('-') or spaces between your Digits, for example: 604 - 233 - 8647

I have had a positive pregnancy test:

Yes or No? (If no please do one and come back to fill out the form)

First day of last menstrual period (LMP):

Please enter the first day of your last mentrual period if you know it (day and month) or type 'I'm not sure'.

I live more than 2 hours from the clinic and would prefer not to have to come in to Willow Clinic.

Type 'Yes' if you would like an 'abortion at a distance’ or 'No' if you can come in to clinic.

I will require a translator for my appointment:

Type 'Yes' if you would like a translator or 'No' if you do not need a translator.

Counselling Options. We have COUNSELLORS or an INFORMATION VIDEO available (see description above under medication abortion). For counselling, I would prefer:

Please type your preferred counselling method. Please type: 'Counsellor', 'Video', 'Either' or 'Not sure'.

Comment

You may also be asked to refer to these forms:

CONSENT Form:

Medical Abortion Consent Form – English .PDF file

Medical Abortion Consent Form – Chinese .PDF file

Medical Abortion Consent Form – Punjabi .PDF file

DIARY Form:

Medical Abortion Diary .PDF file

DO NOT FILL THE FOLLOWING FORM UNLESS ASKED BY OUR STAFF: