Better Access to Birth Control

Intermountain now offers faster access to birth control. If contraceptive care is all you need, simply complete the form below to initiate rapid access to birth control. Once your form is received, you’ll receive a call from a clinical pharmacist within a few hours (if received during business hours) to review your health history and determine the optimal birth control option for you.

The fee for this service is $20 (plus the cost of medication) minus any insurance coverage.

Birth Control Intake Form

Patient Information

First Name
Middle Name
Last Name
Date of Birth
Healthcare Provider's Name
Healthcare Provider's Practice Location
Do you have insurance?
Insurance Information
Current Medications
Any allergies to medications?
If yes, list:
Height
Weight
Phone Number
Email
Mailing Address
City
State
Zip
How did you hear about this online birth control request?
Other

Reproductive History

What was the date of your last PAP?
Was your last PAP smear normal?
Have you ever or are you currently taking birth control? If yes, what kind?
If other, what kind?
Have you had a recent change in vaginal bleeding that worries you?
Have you ever been told by a medical professional not to take hormones?
Have you given birth within the past 21 days?
If yes, how long ago?
Are you currently breastfeeding?

Pregnancy Screening

Did you have a baby less than 6 months ago, are you fully or nearly-fully breast feeding, AND have you had no menstrual period since the delivery?
Have had a baby in the last 4 weeks?
Did you have a pregnancy loss or start you last menstrual period within the past 7 days?
Have you abstained from sexual intercourse since your last menstrual period or delivery?
Have you had a negative pregnancy test in the last 7 days?
Do you think you might be pregnant now?

How long has it been (hours or days) since any of the following occurred:

Had unprotected sex and didn't use any form of birth control; had an issue with your regular birth control method (e.g., the condom broke or slipped); missed a dose (or more) of your regular birth control pill and had sex?

Medical History

Do you have diabetes?
Do you get migraine headaches, or headaches so bad that you feel sick to your stomach, you lose ability to see, it makes it hard to be in the light or involves feeling any numbness?
Are you being treated for inflammatory bowel disease?
Have you ever had a heart attack or stroke or been told you have heart disease?
Have you ever had a blood clot or have you ever been told by a medical professional you are at risk for developing a blood clot?
Have you had a recent major surgery or are you planning to have surgery in the next 4 weeks?
Will you be immobile for a long period?
Have you had bariatric surgery or stomach reduction surgery?
Do you have or have you ever had breast cancer?
Have you had a solid organ transplant?
Do you have or have you ever had hepatitis, liver disease, liver cancer, or gall bladder disease, or do you have jaundice (yellow skin or eyes)?
Do you have lupus, rheumatoid arthritis or any blood disorders?
Do you have high blood pressure or hypertension? OR do you take medications for lowering blood pressure?
When was the last time your blood pressure was checked (at home, in a clinic, or at a store)?
What was your blood pressure reading the last time you had it checked (at home, in a clinic, or at a store)?
Do you take medications for seizures, tuberculosis (TB), fungal infections, or human immunodeficiency virus (HIV)?
Are you a current smoker?
If yes, how many cigarettes per day?
We are currently experiencing intermittent issues with our online forms. If you are not able to submit this form, please call 855-779-3960 for assistance.