Intake — Clínica Médica Aria

Please submit your medical information in advance to schedule an appointment. You will then be routed to our scheduling system.

Are you rescheduling your appointment? If your appointment is more than one day away, use the reschedule link in your "Aria Appointment Information" email. If your appointment is today or tomorrow, then use this form to complete a new intake.

Your private information is kept secure. We do not use your personal information for any reason other than to provide direct healthcare services in compliance with federal and state laws. Aria Medical requires use of texts to your phone for reminders and follow-up.

What is your first name?*

as it appears on your ID

What is your last name?*

as it appears on your ID

Name you wish to be called while you're with us

If you prefer to be called a name other than what's on your ID

Are you the patient?*

Yes, I am the patient/pregnant person scheduling for myself.No, I am a friend or family member scheduling for someone else.

Patients should schedule their OWN appointments. You can share our website with the patient and help them schedule, but do not submit medical information for someone other than yourself. This is to ensure safety and quality care.

In which state do you live?*

Date of Birth*

Your birthday as listed on your photo ID. We are only able to see patients over the age of 18.

Today's Date

Date

Qualifying age

Please provide the best phone number to reach you. We will send appointment confirmations and follow-up surveys to this number. Carrier rates for SMS texts may apply. We will never share your number outside of our system or use it for marketing purposes.

There are restrictions around providing abortion care for minors in Kansas. At this time we cannot schedule patients who are less than 18 years old. Minors can still get abortions in Kansas, just not with Aria. Trust Women and Planned Parenthood do treat minors in Kansas.

If you are under age 18 and traveling from a state that bans abortion, it will be easier to get care in New Mexico, Illinois or Minnesota because these states do not have parental notification laws.

For more help, call:

Chicago Abortion Fund (312) 663-0338

If/When/How Judical Bypass Helpline (844) 868-2812

Jane's Due Process (866) 999-5263 helps minors from Texas get abortion care.

Phone Number*

Please enter a valid phone number.

To be seen at Aria, we need to send you emails. You must print a document from that email and bring it to your appointment, or we can’t see you. We will request a valid email address when you select an appointment time.

Kansas law mandates that we provide you abortion information 24 hours before your appointment.

These documents must be printed on white paper 24 hours before your abortion.

Aria follows the law by requiring you to print these documents on white paper 24 hours before your appointment. You MUST bring the document on paper to your in-person appointment. The documents do not have to be signed, but you must bring them and confirm you printed them at least 24 hours before your appointment.

You MUST print state-mandated documents and bring them to your appointment. You will not be seen on your appointment day if you do not bring the printed documents. Photos or screenshots will not be accepted. By Kansas law, the documents must be printed on white paper.

Have you had an ultrasound (sonogram) for this pregnancy?*

No, I have not had an ultrasound.Yes, I had an ultrasound and will be 11 weeks or less this coming weekend.Yes, I had an ultrasound and will be more than 11 weeks this coming weekend.

Great. We strongly advise bringing a copy of the ultrasound (sonogram) or the report with you to your appointment, if you have it. It will save time in the clinic.

We cannot safely schedule you at Aria if you are more than 11 weeks pregnant. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

When did your last period start?

First day of last period

Have you had positive pregnancy test?*

Yes, my pregnancy test is positive.No, my pregnancy test is negative.No, I have not done a pregnancy test.

You must have a positive pregnancy test before scheduling an abortion appointment. An inexpensive drug store urine test works well. A doctor's office visit is not required to do a pregnancy test.

There are many things other than being pregnant that can make you miss a period. If your pregnancy test is negative, please see a primary care provider to discuss other reasons why you either missed a period or have pregnancy symptoms.

Before this pregnancy how predictable were your menstrual cycles?*

My periods were about the same time every month.My periods were usually the same, but I have skipped some in the last 6 months.My periods are hard to predict.

Were you using a hormonal birth control method when you got pregnant? This includes shots, pills, patches or rings.*

No, I was not using a hormonal birth control method.Yes, I was on a type of birth control.

Are you currently breastfeeding?*

No, I am not breastfeeding.Yes, I am breastfeeding.

We recommend getting an ultrasound (sonogram) locally before you come to Kansas. We can still schedule you with Aria, but people with less predictable periods, those using hormonal birth control, or those who are breastfeeding can sometimes be further into their pregnancy than expected. If you are MORE than 11 weeks at your appointment we will not be able to treat you.

When was the first day of your last menstrual period?

We cannot schedule patients who are more than 11 weeks from their last period.

11 week calc

We cannot safely schedule you at Aria if you are more than 11 weeks pregnant. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead. If you are very close to 11 weeks you may call our team at (316) 350-7688 to discuss.

It looks like you may be less than 5 weeks pregnant.

We go by the first day of your last period, NOT the day you got pregnant.

Abortion pills may not work as well under 5 weeks. When you schedule your appointment, please book a time when you will be at least 6 weeks pregnant to have the best chance of success. We offer weekend appointments up to 14 days in advance.

Which of the following medications are you allergic to?*

I am not allergic to any medications.NSAIDs (ibuprofen, naproxen or aspirin)Antihistamines (includes Dramamine or meclizine)Prostaglandins (includes Cytotec or misoprostol)Mifepristone (RU-486)Other

A medication abortion is not safe for people who are allergic to misoprostol (Cytotec). Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

A medication abortion is not safe for people who are allergic to mifepristone (RU-486). Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you have an IUD in place? Or did you have an IUD placed but never removed? An IUD (intrauterine device) is a small T-shaped device inserted in to the uterus for birth control.

NoYES, I am pregnant and I have an IUD in place now.

It is not be safe to have a medication abortion if you have an IUD. You will need to have the IUD removed before your abortion. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead. You can also call us at (316) 35-7688 if you need help finding someone to remove your IUD.

Have you ever had severe anemia requiring a blood transfusion?*

NoYES

Did this happen the the last 12 months?

Yes, I have needed a blood tranfusion for anemia in the last year.No, my blood transfusion was more than a year ago.

It may not be safe to have a medication abortion if you have needed a blood transfusion in the recent past. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you take blood thinners? These prescription drugs include coumadin (Warfarin), apixaban (Eliquis), rivaroxaban (Xarelto), and heparin.*

NoYES, I take blood thinners.

It may not be safe to have a medication abortion if you take blood thinners. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Have you ever been diagnosed with a bleeding disorder? Examples include Von Willibrand Disease or hemophilia. These rare conditions prevent blood from clotting the way it is supposed to. Anemia is NOT a bleeding disorder.*

NoYES, I have been diagnosed with a bleeding disorder.

It is not safe to have a medication abortion if you have a bleeding disorder. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you use prescription steroid pills, injections or IV infusions more than 5 days a month? Examples include prednisone pills, Solu-Medrol or methylprednisolone. Creams or inhalers do not count.*

NoYES

The abortion pill blocks steroids, so it is not safe to to do a medication abortion if you need regular steroids. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you have severe adrenal problems that have required you to be hospitalized?*

NoYES, I have been hospitalized for adrenal problems.

It is not safe to use the abortion pill if you have adrenal problems. You should have a procedure instead. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you have a severe heart condition? Examples include valve disease requiring you to have a surgery, heart failure or cardiomyopathy. Palpitations or PVCs are not considered a severe heart condition.*

NoYES, I have severe heart problems.

Bleeding from a medication abortion may not be safe for you if you have severe heart disease. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Do you have porphyria? This is an extremely rare condition effecting the liver and skin.*

NoYES, I have porphyria.

It is dangerous for people with porphyria to take the abortion pill. You should have a procedure instead. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Have you ever had an endometrial ablation? This is a procedure that destroys the lining of uterus and is treatment for heavy menstrual periods. Endometrial ablations are uncommon for people of reproductive age.*

NoYES, I have had an endometrial ablation in the past.

Using abortion pills after an endometrial ablation may increase your risk of dangerous bleeding. You should have a procedure instead. Please stop and search abortionfinder.org or ineedana.com to schedule a procedure instead.

Ban state?

Medication Abortion Intake Form