Registration Really, We Make Getting Your IUD A Breeze, Trust Us! Step 1 of 3 33% Were you referred to us from MyIUDSupply.com?*(Did you receive a text msg. or you were referred by your ob/gyn provider?) Yes No OK ..That's great. Please let us know which Ob/Gyn Provider or clinic referred you to get your IUD from us (This will be the location that we will ship your IUD to for insertion once you purchase the IUD) Please find your Providers Office name and correct address from the drop-down list below. (***Please verify the specific office location and address as many Providers have multiple locations***States*StatesAlabamaGeorgiaFloridaNCSCTennesseeMississippiLouisianaIllinoisNevadaArizonaMichiganWisconsinTexasNew YorkCity*CityAtlanta (Central)Providers Name*Provider 1Provider 2Provider 3Practice Name* Practice Address*Gyn-Care Women's Health Center 264 19th Street NW STE 2230First let's see if we offer our services in your city or state. Please choose the Practice Location nearest you if you would like to proceed. Please check the availability of our services in your area.States*StatesAlabamaGeorgiaFloridaNCSCTennesseeMississippiLouisianaIllinoisNevadaArizonaMichiganWisconsinTexasNew YorkCity*CityAtlanta (Central)Practice Address*Gyn-Care Women's Health Center 264 19th Street NW STE 2230I currently do not have an active medicaid, medicare, or MCO policy that provides coverage for IUDs I currently do not have an active medicaid or medicare policy that provides coverage for IUDs I am going to Self-Pay for the IUD?(Not Using Insurance) Yes No Now we need some Registration information from you:Name* First Last Age* Date of Birth* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Phone Number* Email address* Medicaid* Yes No I am going to Self-Pay for the IUD?(Not Using Insurance) Yes No Health Insurance Name* Policy number#* IMPORTANT: We make every effort to verify that the office inserting your IUD/LARC ALSO ACCEPTS your INSURANCE HEALTH PLAN. If for any reason the inserting office does not accept your insurance you have 2 options: 1. Pay the office $150 dollars for the IUD/LARC insertion. 2. Call us to schedule your IUD Insertion at another office.Consent* I have read and agree to Privacy Policy and Terms and Conditions of Use*Consent* I have read and understand Who should not get and IUD.*Patient Consent* By checking this box you agree to have read, understand, signed, and accept the terms and conditions listed in the HIPAA Authorization consent form and Telehealth Consent.*Signature*Date* MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
