Aanmeldformulier

Abortion pill request form - Fill in all details as accurately as possible!

Velden met een * zijn verplicht

Personal data
Name
Initials *
Prefix
Last name *
Address
Street *
House number *
House number addition
Postal code *
City *
Communication
Mobile phone *
Email address *
Identification
Date of birth *
BSN *
Living situation
Indicate your current living or housing situation
Do you have children? If so, how many?
Health care
Pharmacy
Pharmacy name *
City *
Email address *
Medical information
1. I took a pregnancy test that was positive. *
2. What date was that? *
3. What date was the first day of your last menstrual period? *
4. Was your last period (approximately) the same as usual?
5. Is your menstrual cycle regular?
6. I used hormonal contraception when I became pregnant.
7. I am currently using a copper or hormonal IUD.
8. I was breastfeeding in the period I became pregnant.
9. I use medication, namely:
10. Answer the following questions if they apply to you and you have questions for us about them: - Are you likely to have an STD? - Did you become pregnant through non-consensual sex(rape)? See our website for further information about consultations.
Medical history
11. Have you been pregnant before? If so, how often?
12. Have you had an abortion before? If so, how many times?
13. I have had IVF in the past or one of the following gynecological problems: a fallopian tube condition or infection, an ectopic pregnancy or endometriosis.
14. Please indicate if any of the following applies to you: I have porphyria, an adrenal cortex disorder, or a blood clotting disorder; I use blood thinners.
15. Please indicate if any of the following applies to you: severe asthma, severe anemia (Hb 6.0 or less), high blood pressure, or kidney disease.
Ultrasound
An ultrasound is usually not necessary (click for more information). Schedule an ultrasound if you are unsure about the duration of your pregnancy or if you answered "yes" to questions 6, 7, 8 or 13. Upload your results here.
Consent
1. I have understood all questions about my health and have answered them truthfully. *
2. My pregnancy is less than 9 weeks at the time of completing this form. *
3. After considering everything, I have made the decision to terminate my pregnancy voluntarily and without external pressure. *
4. I have been informed about the effects and side effects of the abortion pill and I have fully understood this information. I know what to do in the event of any (rare) complications. *
5. I consent to the use of my information to write a prescription. This prescription will be sent electronically to my preferred pharmacy. I will pick up this recipe myself and use it myself. *
6. I agree to the use of my anonymized data for scientific research. This is not mandatory!
7. For up to two years after this registration, I may be contacted if necessary to participate in scientific research. This is not mandatory!
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