Registration

Practice State*
Practice City*
Practice City*
Practice City*
Practice City*
Practice City*
Practice City*
Practice Location
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Alabama Health Plans*
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Arizona Health Plans*
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California Health Plans*
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Connecticut Health Plans*
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Florida Health Plans*
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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
Which State is your Health Plan through?
Alabama Insurance Plans We Accept
Arizona Insurance Plans We Accept
California Insurance Plans We Accept
Connecticut Insurance Plans We Accept
Florida Insurance Plans We Accept
Georgia Insurance Plans We Accept
Illinois Insurance Plans We Accept
Indiana Insurance Plans We Accept
Iowa Insurance Plans We Accept
Kansas Insurance Plans We Accept
Kentucky Insurance Plans We Accept
Louisiana Insurance Plans We Accept
Michigan Insurance Plans We Accept
Mississippi Insurance Plans We Accept
Nebraska Insurance Plans We Accept
New Jersey Insurance Plans We Accept
New York Insurance Plans We Accept
North Carolina Insurance Plans We Accept
Nevada Insurance Plans We Accept
Ohio Insurance Plans We Accept
Pennsylvania Insurance Plans We Accept
South Carolina Insurance Plans We Accept
Tennessee Insurance Plans We Accept
Texas Insurance Plans We Accept
Washington Insurance Plans We Accept
West Virginia Insurance Plans We Accept
Wisconsin Insurance Plans We Accept
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Health Insurance Name*
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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 see my Health Plan*
Signature*
Date*
MM slash DD slash YYYY
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Comments
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Registration

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Registration

Registration

Step 1 of 2

Contact Us

Useful Links

Areas We Serve

Locations