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Request for Services

Request for Services Form

This online form will take you about 10 minutes to complete and will expedite your check-in process. If you prefer to complete the forms in our office, please arrive 10-15 minutes early for your appointment.


All questions marked with an * are required.

Multi-line address
Indicate your approval for us to contact you.
What Center will you be seen at?
Bend
Madras
Prineville
Redmond
Will the father of the baby be attending with you?
Yes
No
Unsure
Not Applicable
What is your appointment for?

Tell Us About You

Birthday
Month
Day
Year
What is your marital status?
What is your student status?
What is your primary language?
Do you have spiritual beliefs?
Yes
No
What is your religious preference?
Do you have a place of worship?
Yes
No
How did you hear about us?
Are you currently employed?
Yes
No
Who do you live with?

Your Physical History

Are your periods regular?
Yes
No
Have you used any of the following since your last menstrual period? Check all that apply.
Do you want to be pregnant?
Yes
No
Unsure
Are you experiencing any of the following symptoms?
If your pregnancy test is positive, what are your intentions?
Abortion
Adoption
Carry/Parent
Undecided
If you had one of more abortions, did you have any side effects?
If you had an abortion, what is your feeling about your abortion decision?

Father of the Baby

What is your relationship with the Father of the Baby?
Acquaintance
Boyfriend
Ex
Fiancé
Friend
Husband
Other
Do you have future plans with him?
Yes
No
Does he know you are pregnant?
Yes
No
Will he be involved in the pregnancy decision?
Yes
No
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