Request a listing in the Plan C Guide
Please complete this form if you wish to be listed in Plan C's Guide to Finding Abortion Pills (on www.plancpills.org). To qualify for a listing, you must provide a telemedicine abortion option with the medications mailed to patients (i.e. no in-clinic visit or medical testing needed for those who meet basic eligibility requirements). If you have any questions, please email info@plancpills.org 
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Full Name of person completing this form
Your title
Email
Phone
Website URL
Brief description of your service (1-3 sentences, max).
What states do you serve with Telemed Abortion with Mailed Pills?
Typical days between patient first contact and receipt of pills (i.e. 3 days, 5-7 days, 1-2 weeks, etc.)
LMP cut off for Telemed Abortion with Mailed Pills?
Cost of Telemed Abortion with Mailed Pills?
Cost Details (i.e. any discounts or sliding scales?)
Insurance accepted?
Medicaid accepted?
Details about the Follow-up Support you Offer
Phone support? Text support? 24/7 coverage? Does price include follow up procedure if needed?
What type of visit do you require?
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Any medical tests required?
Do you require ultrasound or blood work for patients within 70 days LMP who have no medical contraindications (irregular periods, history/symptoms of ectopic, etc)?
How did you hear about the Plan C Guide to Finding Pills?
Have you downloaded our toolkit (available at https://familymedicine.uw.edu/accessdelivered/)?
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Anything else we should know?
Thank you.
By submitting this form you give us permission to publish your service and contact you. We will confirm with you once your service is published so that you can review the listing, and we will contact you if we need more information.
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