Abortion Cost Assistance Patient Intake Form

Blog
Operation Free Women
- Abortion Cost Assistance Patient Intake Form
- Policy and Disclaimer

We currently have funds available to disburse. This note will be updated once a week.

Please enter your contact and submission information below. We will be contacting new patients back in the order of receipt.
(Please note we are not a clinic or women’s center)
– Operation Free Women

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Thank you for your response. ✨

All submitted information will be kept confidential between only staff of Operation Free Women and the Patient.

Patient Name

Patient Email

Patient Personal Phone

Can we contact you via text/email/phone call?

How far along are you in your pregnancy?

What State do you currently reside in?

Is a 24-hour notice at a clinic scheduled?

Is an abortion clinic procedure scheduled?

Can you travel to California, Nevada, or Arizona?

Would you be comfortable providing an abortion clinic bill for us to pay or providing your abortion clinic a temporary exchange of information that expires once the bill is paid?

Blog
Operation Free Women
- Abortion Cost Assistance Patient Intake Form
- Policy and Disclaimer

Operation Free Women

Abortion Cost Assistance Patient Intake Form

Thank you for your response. ✨

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