Just The Pill offers sexual and reproductive healthcare by mail to rural Minnesota.

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If you want birth control or STI treatment, please complete the following steps.

Step One. Read and sign the following form (the form will appear in a new window):
“Consent – Telehealth Services“
Step Two. Answer the questions below.
Step Three. Schedule a consultation by phone with our doctor.

Do you need an interpreter? We are committed to meeting the communication needs of our clients. Interpreting services are available. Please contact us.

Birth Control or Sexually Transmitted Infection (STI) treatment

Please read our Privacy Statement.

I agree to answer all questions truthfully and consent to sharing this information with the medical team. I agree that my anonymous data could be used for research and advocacy purposes. I understand that this service requires me to use email for communication about my care (unencrypted email is usually secure, but may not be 100% secure). I consent to this. All identifying information will remain confidential. I can withdraw my consent at any time by emailing pill@justthepill.com. *

How can we help?

I would like to get birth control.
I want to know more about STI treatment.

Select the month and the first day of your last regular menstrual period:

Have you been on birth control before? *

Which method(s) of birth control have you used?

Are you experiencing symptoms of a sexually transmitted infection (STI), or have you been exposed to an STI?

Do you have any health conditions or diseases of your lungs, heart, kidneys, liver, thyroid, or any mental health issues or is there any other important information the doctor should know about you? *

If yes, please explain:

Do you take any regular prescription medications? *

If yes, which medication(s) do you take?

Do you have any allergies to any medications? *

If yes, what are they?

How old are you? *

Your name and address

Please give your correct name and address. All correspondence will be sent to your email address. All information will remain confidential.

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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