Registration

Practice State*
Practice City*
Practice City*
Practice City*
Practice City*
Practice City*
Practice City*
Alabama Health Plans*
Arizona Health Plans*
California Health Plans*
Connecticut Health Plans*
Florida Health Plans*
Georgia Health Plans*
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Practice Name*
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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
We do not accept Medicaid, MCO's, or Medicare
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.*
Patient Consent*
I do not have a Medicaid, MCO's, or Medicare policy*
Signature*
Date*
MM slash DD slash YYYY
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Phone
This field is for validation purposes and should be left unchanged.

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