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Male Female Other

    1 - What is the reason you are using RedBox Rx today?*

  • Refilling an existing birth control prescription
    Starting birth control for the first time
    Restarting birth control
    Changing birth control
    Other

    • 2 - What was your last blood pressure reading? *


    • You can find this information from a recent medical visit or by taking your blood pressure at a local pharmacy or grocery store. If you're not sure you can leave this blank.

    3 - Do any of the following situations apply to you?*

  • I am currently pregnant
    Deep venous thrombosis
    HIV
    History of pulmonary embolism
    Have cancer, had cancer, or being tested for cancer now
    Had an allergic reaction to birth control medicines before
    Systemic lupus erythematosus (SLE) with positive or unknown anti-phospholipid antibodies
    Positive or unknown anti-phospholipid antibodies
    Liver problems or history of liver problems Stroke
    Surgery or medical condition that affects ability to absorb food or medicine properly, such as gastric bypass or a shortened intestine
    None apply
    • Select all that apply to you. In certain situations or medical issues, hormonal birth control may not be appropriate to use.

    4 - Do any of these risk factors apply to you?*

  • Smoke cigarettes, e-cigarettes, or use other tobacco products
    Given birth in the last 6 weeks Breastfeeding
    Abnormal vaginal bleeding different from my usual period
    Periods have become more frequent or heavier than my usual period
    Gallbladder problems and still have my gallbladder
    Get blood clots, or my family members get blood clots such as deep venous thrombosis (DVT) or pulmonary embolism (PE)
    Conditions that thicken the blood (coagulopathy)
    Unable to move for long periods of time, such as wheelchair-bound or in recovery after major surgery
    Ulcerative colitis or Crohn's disease
    Organ transplant
    None apply
    • Select all that apply to you. It's not always appropriate to take combination (estrogen based) hormonal birth control as there are increased risks of major side effects including blood clots or stroke.

    5 - Do you have high blood pressure, high cholesterol, diabetes, vascular disease, and/or heart problems (including heart attack and heart valve problems) which makes it unsafe to take combination birth control?*

  • Yes
    No

    • 6 - Have you been diagnosed with migraine headaches? *

  • Yes
    No
    • Certain migraine headaches can increase your risk of stroke and death with hormonal birth control.

    7 - Over the past 2 weeks, how often have you had symptoms of depression (feeling down, little interest in doing things) or anxiety (feeling nervous or worrying too much about different things)?*

  • Not at all
    Several days
    More than half of the days
    Nearly every day

    • 8 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • 9 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    10 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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