Medication Abortion Booking Form

MAKE SURE YOU HAVE READ ALL THE INFORMATION
ABOUT MEDICATION ABORTIONS ON OUR “ABORTIONS” PAGE.

Mifegymiso: You will need to be 10 weeks or less from the first day of your last period
on the day that we are able to see you. ( fee = $25.00 )

If you feel you will qualify for the appointment please fill out the form below.

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: 604-709-5611

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

PLEASE MAKE SURE TO HAVE YOUR BC MEDICAL CARD NUMBER WITH YOU WHEN WE CALL ( If you have one )

Have you READ ALL THE INFORMATION ABOUT MEDICATION ABORTIONS ON OUR “ABORTIONS" PAGE?

Yes or No? - If not, please READ it Prior to Booking an Appointment.

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 604-709-5611 - We are usually booking within a few days so will do our best to respond promptly. - If you feel you will qualify for the appointment please fill out the form below.

Leave this box blank - Proceed to Answer the Questions BELOW ...

Type your name above

Please contact me at this phone number: *

Please enter the # with HYPHENS or spaces between your Digits, Eg. 604 - 233 - 8647 - Thank you

First day of last menstrual period (LMP): *

Day - Month