Request An Appointment at abortion clinic

REQUEST AN APPOINTMENT

To “request” an appointment for an abortion, please fill out the following form.

You will receive an email confirmation when your appointment request has been received.
If you are using private insurance or Medicaid you must provide all requested insurance information so we may verify your insurance information prior to the date of your appointment and you must make your appointment for at least the second business day from today to allow sufficient time to confirm your insurance.
Please be advised that all credit card transactions will be subject to an additional transaction fee.

We may call you at the telephone number you provide – make sure you provide a number where you can receive calls.

Patient's Full Name*
Patient's Telephone Number*
Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Patient's Email Address*
Social Security Number*
Date of Birth*

MM slash DD slash YYYY
Name of Insurance Carrier
Insurance ID Number
Insurance Phone Number (found on the back of insurance card)
Date of Last Menstrual Period*

MM slash DD slash YYYY
Allergies
Medical / Health Problems
I have reviewed the Patient Notifications*
- Yes
- No
Click Here to review Patient Notifications.
How did you hear about us?*
- Abortion Clinics Online Directory
- Google / Bing / Yahoo search
- Friend / Family Member
- Doctor
- Insurance Provider
- Other
CAPTCHA

Confidentiality Notice
The information asked online is no different than what you would be asked over the telephone. Your information will be transmitted by secured, encrypted e-mail. Though we make every effort to keep your information secure, it is still possible that the information you provide could be captured by individuals who are engaged in illegal internet observance. By providing and submitting your confidential information, you accept the risk of sending this information by e-mail to Pilgrim Medical Center’s personnel. When submitting by e-mail, you also agree not to hold Pilgrim Medical Center, including its employees or agents, liable for any damages you may incur as a result of the transfer or use of this information.

NOTICE: Users may not post or transmit any message that is libelous or defamatory, or violates any other person’s privacy rights or rights in other confidential information. Users may not post or transmit any message, data, image, or program with the intent to threaten the safety of others and/or with the effect of causing a reasonable person to perceive a threat to his or her safety.