Name *

Phone *

Email *

Consent to Telemedicine

Telehealth involves the use of live audio-video or other forms of synchronous and asynchronous electronic communications to deliver health care services to patients while the health care provider (Provider) is located at a physical location different from the patient receiving the health care services (Telehealth Services).

By agreeing to receive Telehealth Services from Life Cycle for Women, LLC and AB Telemedicine Care, PLLC (Medical Practice) via all websites provided by (“Life Cycle for Women”, “we”, “us” or “our”), including the Site hosted on the domain [https://lifecycleforwomen.com] (collectively, “Sites”), and all services provided by us in connection with such Sites or otherwise (Life Cycle for Women Platform).

I acknowledge that:

There are potential risks to using electronic communications for the purpose of a health care visit, including, but not limited to, service interruptions, unauthorized access, technical difficulties, call termination or other equipment failures. I acknowledge and accept those risks, understanding there are alternatives to receiving Telehealth Services.
I will receive protected health information via email or SMS text messaging. I understand that messages shared through these communication channels may not be secure in every instance.
Either I or the Provider can discontinue Telehealth Services if either of us determines that Telehealth Services are not right for my health care.
It is my responsibility to provide accurate, complete, and current information about me and my health condition(s) to the Provider while receiving Telehealth Services.
The Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with Telehealth Services. I am also responsible for mitigating any risks to my privacy or confidentiality stemming from the location or circumstances of my participation in Telehealth Services (e.g., joining the telehealth encounter from a quiet space, ensuring others do not overhear my conversation or see my computer or mobile device screen). All existing confidentiality protections under federal and state law apply to my information disclosed during Telehealth Services
I understand and acknowledge that Telehealth Services are not intended to be, and do not act as, emergency services. If I am experiencing an emergency, I should not rely on Telehealth Services and instead should call 911 or go to an emergency department.
I understand what it means to receive Telehealth Services and am legally authorized to acknowledge, agree, and consent to the use of Telehealth Services.
I am responsible for all charges (a) that I may incur from my mobile or internet service provider, as applicable, when receiving Telehealth Services.

By continuing, I, the patient, hereby:

Represent that I have read and understand this Consent to use Telehealth Services and the anticipated benefits and risks of the use of telehealth provided to me through the Life Cycle for Women Application. I hereby consent to receive Telehealth Services from providers engaged through the Life Cycle for Women Application.

I hereby give my informed consent for the use of telemedicine in my medical care. *

Yes

PATIENT AGREEMENT FORM

Mifepristone Tablets, 200 mg

Healthcare Providers: Counsel the patient on the risks of mifepristone. Both you and the patient must provide a written or

electronic signature on this form.

Patient Agreement:

1. I have decided to take mifepristone and misoprostol to end my pregnancy and will follow my healthcare provider's advice about

when to take each drug and what to do in an emergency.

2. I understand:

a. I will take mifepristone on Day 1.

b. I will take the misoprostol tablets 24 to 48 hours after I take mifepristone.

3. My healthcare provider has talked with me about the risks, including:

• heavy bleeding

• infection

4. I will contact the clinic/office/provider right away if in the days after treatment I have:

• a fever of 100.4°F or higher that lasts for more than four hours

• heavy bleeding (soaking through two thick full-size sanitary pads per hour for two hours in a row)

• severe stomach area (abdominal) pain or discomfort, or I am “feeling sick,” including weakness, nausea, vomiting, or

diarrhea, more than 24 hours after taking misoprostol – these symptoms may be a sign of a serious infection or another

problem (including an ectopic pregnancy, a pregnancy outside the womb).

My healthcare provider has told me that these symptoms listed above could require emergency care. If I cannot reach the

clinic/office/provider right away, my healthcare provider has told me who to call and what to do.

5. I should follow up with my healthcare provider about 7 to 14 days after I take mifepristone to be sure that my pregnancy has

ended and that I am well.

6. I know that, in some cases, the treatment will not work. This happens in about 2 to 7 out of 100 women who use this treatment. If

my pregnancy continues after treatment with mifepristone and misoprostol, I will talk with my provider about a surgical procedure

to end my pregnancy.

7. If I need a surgical procedure because the medicines did not end my pregnancy or to stop heavy bleeding, my healthcare

provider has told me whether they will do the procedure or refer me to another healthcare provider who will.

8. I have the MEDICATION GUIDE for mifepristone.

9. My healthcare provider has answered all my questions.

Patient Signature *

Clear

Patient Name (Print) *

Date *

Provider Name (Print)

Provider Signature (for office use only)

Clear

Date

I hereby consent to receive Email/SMS text messages from Life Cycle for Women to include order status information. *

Yes

We offer personalized/compassionate follow-up care options. Would you be interested? *

Yes

Do you understand your pills must be shipped to a Massachusetts or New Hampshire address? *

Yes

Your medication will be sent to this address.

Address *

City *

Postal code *

Are you over the age of 18? *

Yes

Date of Birth *

Please upload a picture of the front of your ID *

Please upload a picture of the back of your ID *

Do you currently have an IUD in place?

An IUD is a type of birth control that is placed inside your uterus by a doctor. People usually call IUDs by their brand names: Mirena, Skyla, Liletta, Kyleena, or Paragard. *

Yes

I'm not sure

Did you have an IUD in place when you became pregnant? *

Yes

I'm not sure

Have you been on hormonal birth control at any time in the past three months?

Hormonal birth control includes: the pill, the patch, the ring, the shot, the implant, and/or the hormonal IUD.

Yes

I'm not sure

Have you ever had an ectopic pregnancy?

An ectopic pregnancy is a pregnancy outside of the uterus. *

Yes

I'm not sure

Have you had your tubes tied or had any other pelvic surgery?

Getting your tubes tied also called a tubal ligation is a surgery done to prevent future pregnancies *

Yes

I'm not sure

Do you take blood thinners regularly?

Blood thinners are medicines prescribed by a doctor to treat rare conditions, like blood clots. Some examples of blood thinner medicines include: apixaban (Eliquis), dabigatran (Pradaxa), enoxaparin (Lovenox), rivaroxaban (Xarelto), and warfarin (Coumadin) *

Yes

I'm not sure

Have you taken a daily oral steroid medicine medication for the past 6 months or more?

Steroid medications we are referring to here are pills taken by mouth or shots that are prescribed by a doctor to treat different things including autoimmune diseases or if you've had an organ transplant. Some examples of oral steroids include: prednisone, cortisone, dexamethasone, prednisolone, and others.

Yes

I'm not sure

Please check off if any of the following apply to you (check all that apply) *

Allergy to prostaglandins, misoprostol or mifepristone

Chronic adrenal failure

Hemorrhagic disorder or bleeding problems (any condition in which your blood does not clot normally, which can make you bleed a lot after an injury or surgery)

Pelvic Inflammatory Disease treated with IV antibiotics

Inherited porphyria

Do you have any other major medical diagnosis?

No, I haven't been diagnosed with these conditions

Have you ever been diagnosed with symptomatic anemia that has required a blood transfusion? *

Yes

I'm not sure

Have you experienced any of the following in the last week?

Dizziness, fainting, heart palpitations, or trouble breathing? *

Yes

I'm not sure

Have you had an abortion treatment in the past three months? *

Yes

I'm not sure

List any medications you take. If none, enter None. *

List any allergies you may have. If none, enter None. *

Emergency Contact Info

How many children have you given birth to?

How many living children do you have now?

Not counting this pregnancy, how many prior abortions have you had?

How many times have you miscarried naturally?

Have experienced any abdominal pain in the last seven days?

Yes

Do you currently have any sexually transmitted diseases?

Yes

I'm not sure

Please list any STD's you may have

Do you smoke tobacco or any other substance?

Yes

Please list any tobacco or other substances you may smoke

Have you ever conceived through IVF (In Vitro Fertilization)?

Yes

Please list the date you conceived through IVF