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.

Online care is available only while you are physically in Texas. Please call (940) 257-2002 and we will help you find the right next step.

Your date of birth *

About You

Legal first and last name * Street address * City * State * ZIP code * Mobile phone * Email * How may we contact you about this care? Because this care is time-sensitive, we may need to reach you quickly. * Phone call Text message Secure portal message May we leave a generic voicemail (no medical details)? * Yes No

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. We read the name and date of birth from the ID, they must match this form, and your selfie is matched to the portrait on the ID. Your ID and selfie are stored only in your secure chart.

If your ID cannot be verified, your care is pickup-only: the Clinician may ask you to complete a video visit or come in person, and any prescription is sent for pharmacy pickup only, where your government photo ID is checked again at the counter. If your ID cannot be verified, a video visit may be needed first.

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. * The payment card I use will be in my own name, matching my ID. *

Timing: When It Happened

Timing decides everything in emergency contraception, so please be as exact as you can. The Clinician uses the time you give here to place you in a window: 0–24 hours, 24–72 hours, or 72–120 hours after unprotected sex. Levonorgestrel can be considered up to 72 hours; ulipristal can be considered up to 120 hours. After 120 hours, emergency pills are no longer an option through this form — please call us right away instead.

Date of the unprotected sex or birth control failure * Time of the unprotected sex or birth control failure (best estimate, include AM/PM) * About how many hours ago was that? * Less than 24 hours ago (0–24 hour window) 24 to 72 hours ago (24–72 hour window) More than 72 hours and up to 120 hours ago (72–120 hour window) More than 120 hours ago (over 5 days) Unsure

What happened? Check all that apply. * No birth control was used Condom broke, slipped, or was not used the whole time Missed birth control pills, or patch/ring was late, off, or out Birth control may have failed for another reason Other Describe what happened, if helpful Since your last period, was there any other time you had unprotected sex or a possible birth control failure — including earlier in this cycle? * No Yes Unsure If yes or unsure, give the date(s) as best you can

This matters because emergency contraception addresses the most recent episode. An earlier episode could mean a pregnancy is already possible, and the Clinician will work through that with you in Section F.

Have you already taken an emergency contraception pill for this episode? * No Yes If yes: which pill, on what date and at what time, and did you vomit within 3 hours of taking it?

Menstrual and Pregnancy History

Date your last period started * Are your periods regular? * Yes No Unsure Was your last period normal for you in timing, length, and flow? * Yes No Unsure Could you already be pregnant from an earlier episode — before the one in Section E? * No Possibly Yes

Home pregnancy test * Not taken Negative Positive Unsure of the result

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

If a pregnancy is already possible from an earlier episode, the Clinician may ask you to take a home pregnancy test before deciding. A test taken today can only speak to episodes from earlier cycles of timing — it cannot rule out a pregnancy from the most recent episode, which is why the follow-up test in Section M matters.

Are you currently breastfeeding, or did you give birth in the last 6 months? * No Yes If yes: delivery date and breastfeeding status

Effectiveness and Safety Screen

Some medicines and health details can make emergency contraception less effective or change which option fits you best. Answer honestly — a "yes" does not end your care; it helps the Clinician choose the option most likely to work for you.

Do you take any of these medicines? They can make emergency contraception less effective. * Rifampin or rifabutin (tuberculosis medicines) Certain seizure medicines (carbamazepine, phenytoin, topiramate, primidone, others) Certain HIV medicines St. John's wort None of these Unsure Are you currently using hormonal birth control (pill, patch, ring, shot, implant, or hormonal IUD), or have you used it in the last 7 days? * No Yes Unsure If yes: which method, and when did you last take, apply, or receive it? Have you ever had an allergic or serious reaction to levonorgestrel (Plan B and similar) or ulipristal (ella)? * No Yes Never taken either If yes, describe — include dates the reaction Do you have severe liver disease, or have you been told you have a liver condition the Clinician should know about? * No Yes Unsure If yes or unsure, details Have you had bariatric or weight-loss surgery that affects how pills are absorbed, or a condition that affects absorption (for example, vomiting or severe diarrhea today)? * No Yes If yes, describe — include dates

Health History

Check every condition you have now or have had before: * Ectopic (tubal) pregnancy Pelvic inflammatory disease Sexually transmitted infection Severe abdominal or pelvic pain in the past month Liver disease Seizure disorder Diabetes or prediabetes High blood pressure Depression, anxiety, or other mental health condition Other None of the above If yes, describe — include dates Any abdominal or pelvic surgery? * No Yes If yes, describe — include dates

Medicines, Allergies, Previous Use

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) * Have you used an emergency contraception pill before? Check all that apply. * Levonorgestrel (Plan B and similar) Ulipristal (ella) Unsure which one Never used one For each time you used one: when, any side effects, and whether your next period came Have you ever had a severe headache change, heavy prolonged bleeding, or a serious reaction after emergency contraception or hormonal birth control? * No Yes If yes, describe — include dates

Safety and Wellbeing

Do you feel safe and able to consent in your sexual relationship(s)? * Yes No 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

Any concern about a sexually transmitted infection, or need for testing? * No Yes

Emergency contraception protects against pregnancy only — it does not protect against sexually transmitted infections. If you had unprotected sex, STI testing is a healthy next step, and Section M explains the timing the Clinician will confirm with you.

Measurements

Height * Weight *

Your weight helps the Clinician choose the emergency contraception option most likely to work well for you. It is one part of the review, shared only with your care team.

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

How You Will Receive Medication

PICKUP IS THE DEFAULT FOR EMERGENCY CONTRACEPTION — and it is strongly recommended. Pickup protects your timing: the prescription goes to the pharmacy you name, and you can take the pill the same day. If the Clinician prescribes, your prescription will be sent to your own pharmacy for pickup, and 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) * Can you pick up the medication today, as soon as it is ready? * Yes No If no: when is the earliest you can pick it up, and is there another pharmacy that would be faster for you?

Follow-Up Guidance, What Happens Next + Consent

What happens next: a Clinician reviews your answers during clinic hours, as promptly as timing allows. The Clinician may ask follow-up questions, verify your identity and location, ask you to take a pregnancy test before deciding, convert your case to a video visit, arrange an in-person visit, or explain that emergency contraception is not the right fit and help you with next steps. No medicine is promised.

Follow-up guidance the Clinician will confirm with you:
• Pregnancy test: take a home pregnancy test 3 weeks after the unprotected sex, or sooner if your period is more than 7 days late — whichever the Clinician advises for your dates. If the test is positive, or if you develop severe abdominal or pelvic pain at any point, contact us or seek care promptly.
• Your next period: it may come a few days earlier or later than expected, and flow may differ for one cycle. If it has not come within 3 weeks, take the pregnancy test above and contact us.
• STI testing: emergency contraception does not protect against sexually transmitted infections. Testing after unprotected sex is recommended — the Clinician will confirm the right timing and can arrange testing at our Denton clinic.
• Ongoing birth control: emergency contraception protects against this episode only, not later ones. The Clinician will help you start or restart a regular method and will tell you how long to use a backup method such as condoms.
• Feeling unwell after taking it: nausea and a next-period change are common. If you vomit within 3 hours of taking the pill, contact us the same day so the Clinician can advise you.

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.

Type your full legal name to confirm each statement:

The information I provided is complete and accurate to the best of my knowledge. I am 18 years of age or older, I am physically located in Texas, and the identity information I provided is my own and is true. I listed all medicines, supplements, allergies, and relevant health conditions. I understand a Clinician may require video, examination, records, photographs, or laboratory or pregnancy testing before deciding. I understand submitting this form does not guarantee treatment or a prescription. I understand telehealth has limits and I may be directed to urgent, emergency, specialist, or in-person care. I understand emergency contraception is time-sensitive, works only within 72 hours (levonorgestrel) or 120 hours (ulipristal), and does not protect against sexually transmitted infections. I understand emergency contraception will not be prescribed if I am already pregnant, and that I will take the follow-up pregnancy test as advised in this form. I will seek emergency care for any emergency warning symptom listed at the top of this form. I consent to telehealth care and understand a Clinician will review my information. I authorize payment as described above — the review fee is charged once a Clinician completes the review, whether or not treatment is approved. Full legal name (acts as your signature) *

⚠ Emergency Contraception Is Time-Sensitive