Registration Really, We Make Getting Your IUD A Breeze, Trust Us! IMPORTANT! Please check the availability of our services in your area. *Required Step 1 of 3 33% First 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 do not proceed if you do not see a current location. Please check the availability of our services in your area.This field is hidden when viewing the formStates*StatesAlabamaGeorgiaFloridaNCSCTennesseeMississippiLouisianaIllinoisNevadaArizonaMichiganWisconsinTexasNew YorkThis field is hidden when viewing the formCity*CityAtlanta (Central)This field is hidden when viewing the formPractice Address*Gyn-Care Women's Health Center 264 19th Street NW STE 2230 Please indicate what payment method you will choose to purchase your IUD.Payment Method* Insurance Plan Self Pay 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* Office Location Code for Insertion BOXGA01GA012FL01FL12SC01Consent* 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.*I 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 Signature*Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.