JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Best Chemist Online
The person who will take the pills should fill out this form. The doctor must be in touch with that person directly.
US Based orders are shipped and delivered within 2-3 working days. Overseas orders may take between 2-3 days. The cost is $125
The helpdesk and doctor are here to support you through the whole process. It is safe to use abortion pills at home as long as you have good information and access to emergency care in case of rare complications.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email*
*
Your answer
Full Name*
*
Your answer
If successful, you will receive a payment link via CashApp or our other payment channels
*
Understood
Understand: You will be sent a payment link as an invoice via email. This payment will need to be made within the day of receipt to ensure on time delivery. The item on the payment link will be “abortion consultation”.
*
I have read this
Understand: You will be sent a payment link as an invoice via email. This payment will need to be made within the day of receipt to ensure on time delivery. The item on the payment link will be “abortion consultation”.
*
I have read this
Date Of Birth*
*
MM
/
DD
/
YYYY
How long have you been pregnant? (Gestational Age: It is measured in weeks, from the first day of women’s last menstrual cycle to the current date)
*
0-8 Weeks
9-12 Weeks
12 Weeks & Above
Not pregnant, I want to order for future use
Other:
Do you have any of the following illnesses: an allergy to Misoprostol or Mifepristone or another prostoglandin; chronic adrenal failure; hemorrhagic disorder (bleeding disease); or inherited Porphyrias?
*
I don't have an allergy to Misoprostol or Mifepristone or another prostoglandin; chronic adrenal failure; hemorrhagic disorder (bleeding disease); or inherited Porphyrias
I have one of the above mentioned diseases.
Other:
Do you have any health conditions or diseases of your lungs, heart, kidneys, liver, thyroid, or any mental issues or is there any other important information the doctor should know about you?
*
no
if yes, please provide details below
Other:
Do you take any regular prescription medications?
*
no
if yes, please provide an answer below
Other:
Do you have any allergies to any medications?*
*
If yes, please provide these details
no
Other:
Other thoughts or comments
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms