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Contraceptive Refills

When you pick up your refill you may pay cash, check, credit card or charge it to your UAA student account.

Blue Cross/Blue Shield and United Health Care will be billed by the Student Health and Counseling Center on your behalf.

Today's Date:

mm/dd/yy

First Name:

Last Name:

Current Telephone Number:

Student ID#:

Date of Birth:

mm/dd/yy

Contraception currently taking:

How many refills do you need?:

We encourage you to purchase 3 or more until your next annual is due.

Abdominal Pain:

yes

Chest Pain:

yes

Headaches:

yes

Double Vision:

yes

Severe Depression:

yes

Pain or swelling in the legs:

yes

Regular Cycle? :

Yes

On the 4th week of your contraceptives, do you have bleeding or spotting?

Any questions about your Birth Control?:

Page Updated: 4/29/11 By: