Demo Intake — Birth Control | Evolve Health (Preview)

Step — Eligibility gates

Are you having any urgent symptom listed above right now? *

No Yes

I confirm each of the following (all must apply): *

I am 18 years of age or older. I am physically located in Texas during this evaluation. I understand this is not emergency care. I understand a Clinician will review my answers and treatment is not guaranteed.

Your date of birth *

Step — About you

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care? *

Phone call Text message Secure portal message

May we leave a generic voicemail (no medical details)? *

Yes No

Step — Identity verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart. If your ID cannot be fully verified, any prescription is pickup only.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Take a photoDemo only — files are never uploaded.Upload a photo

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Take a photoUpload a photo

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Take a photoUpload a photo

The name and date of birth on my ID match the information on this form. *

Step — Your concern and goals

What would you like help with? Check all that apply. *

Start birth control Switch birth control method Refill current method Emergency contraception (unprotected sex or method failure) Discuss which option fits me best Lighter or less painful periods Acne or excess hair growth Endometriosis or PCOS symptom control Other

Your main goal for this visit

Which methods do you want to discuss? Check any.

The pill, patch, ring, and progestin-only pill can be prescribed online if you are eligible. The shot, implant, and IUDs are placed in person at our Denton clinic — if you choose one of those, we will book you in person instead of prescribing online.

Step — Menstrual and pregnancy history

Date your last period started *

Are your periods regular? *

Yes No Not applicable (no periods / continuous method)

Could you be pregnant right now? *

No Possibly Yes

Home pregnancy test *

Not taken Negative Positive Unsure

If you took a home pregnancy test, on what date?

Date of last unprotected sex (needed only for emergency contraception timing)

Are you currently breastfeeding, or did you give birth in the last 6 months? *

No Yes

If yes: delivery date and breastfeeding status

Do you plan a pregnancy in the future? If so, roughly when?

Step — Estrogen safety screen

The pill, patch, and ring contain estrogen. Estrogen methods are not safe for everyone. Answer honestly — a "yes" does not end your care; it helps the Clinician choose a safe method, which may be a progestin-only or non-hormonal option.

Explain any item you checked

Do you take any of these medicines? They can make hormonal birth control less effective.

Rifampin or rifabutin (tuberculosis medicines) Certain seizure medicines (carbamazepine, phenytoin, topiramate, others) Certain HIV medicines St. John's wort None of these Unsure

Have you had bariatric or weight-loss surgery that affects how pills are absorbed? *

No Yes

If yes, describe — include dates

Step — Health history

If yes, describe — include dates

Any abdominal, pelvic, or bariatric surgery? *

No Yes

If yes, describe — include dates

Family history: blood clots, stroke, or heart attack before age 50, or breast/ovarian cancer in close relatives? *

No Yes Unsure

If yes, describe — include dates

Step — Medicines, allergies, previous methods

List every prescription medicine, over-the-counter medicine, vitamin, supplement (including St. John's wort), and recreational substance you currently use. Include dose and how often you take it. *

Medication allergies or serious reactions (write "None" if none) *

For each method you used: how long, any side effects, and why you stopped

With birth control, have you ever had a blood clot, a severe headache or migraine change, a large rise in blood pressure, a severe mood change, or heavy prolonged bleeding? *

No Yes

If yes, describe — include dates

Step — Lifestyle and wellbeing

Tobacco or nicotine: type and amount per day (this affects method safety). Write "None" if none. *

Alcohol: drinks per week *

Do you ever have 5 or more drinks on one occasion? *

No Yes

Cannabis or other recreational substances? *

No Yes

Typical sleep: hours per night

Physical activity *

Little or none 1–2 days per week 3 or more days per week

Recent major stress, grief, or relationship change? *

No Yes Prefer to discuss

During the past 2 weeks, have you often felt down or depressed, or had little interest or pleasure in things? *

No Yes

Are you currently thinking about harming yourself or someone else? *

No Yes

Do you feel safe and able to consent in your sexual relationship(s)? *

Yes No Prefer to discuss

Any concern about a sexually transmitted infection, or need for testing? *

No Yes

Step — Measurements

Height *

Weight *

Blood pressure — top number (systolic) *

Blood pressure — bottom number (diastolic) *

Date the blood pressure was taken *

Where was it measured? *

Home cuff Clinic or pharmacy Other

A recent blood pressure reading is needed before estrogen-containing methods (pill, patch, ring) can be prescribed. If you do not have a recent reading, most pharmacies will check it free — please get it checked and enter it here. If your reading is 140/90 or higher, the Clinician may recommend a progestin-only method or an in-person visit instead.

Who is your primary care clinician, and when was your last visit?

Recent labs we should know about

Blood sugar / A1c Cholesterol None or unsure

Lab dates and results, if known

Step — How you will receive medication

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.

Pharmacy pickup: *

Pharmacy pickup — prescription sent to the pharmacy I name below Mail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Pharmacy name and city (for pickup) *

Step — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; ask you to confirm blood pressure or take a pregnancy test before prescribing; request records or lab tests; schedule a video or in-person evaluation; explain that the implant, IUDs, and the shot require an in-person visit; treat emergency contraception as urgent; or recommend primary care, OB-GYN, or emergency evaluation. No medicine or device is promised.

Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

Full legal name (acts as your signature) *

Step — Eligibility gates

Step — About you

Step — Identity verification

Step — Your concern and goals

Step — Menstrual and pregnancy history

Step — Estrogen safety screen

Step — Health history

Step — Medicines, allergies, previous methods

Step — Lifestyle and wellbeing

Step — Measurements

Step — How you will receive medication

Step — What happens next + consent

Please get help right away

Demo complete.