Call Us
Book Appointment
New Patient Intake Packet (English) — A-All Women Care
A
A-All Women Care
Las Vegas Abortion Clinic · lvabortion.com
English Español

New Patient Intake Packet

Please complete every page below before your visit. Your information is confidential and reviewed only by our clinical team.

🔒 Secured & HIPAA-aware form submission
Step 1 of 11

Patient Information

Información Del Paciente

Marital Status

Select one

Race

Select one

Ethnicity

Hispanic or Latino?

Step 2 of 11

Emergency Contact Information

En Caso de Emergencia Notifique

Step 3 of 11

Insurance Information

This clinic does not bill insurance for abortion services — this section is for lab/office-visit reference only.

Primary Insurance

Secondary Insurance

Step 4 of 11

Social History

Sexual Orientation

Highest Education Level

Current Gender Identity

Step 5 of 11

Pregnancy History

Step 6 of 11

VIP Short Patient History

Historial Breve del Paciente — clinical screening questions reviewed by your provider.

Allergies & Medications

Please answer Yes/No — explain any "Yes"

Medical History Checklist

Check all that apply — circle/explain any medications or complications with our staff

By continuing, I certify that the information I have provided is true, correct, and complete.
Step 7 of 11

Clarification of Charges

Please review our pregnancy termination service fee schedule below.

Pre-Procedure Charges
Consultation$275
Ultrasound$290
Rh Factor Testing$110
HCG Testing$70
Syphilis Testing$70
Medical Termination
Uncomplicated Medical Termination$850
Follow-up Pelvic Ultrasound$70
Office D&E — Failed Medical Termination$575
Emergency D&E — Heavy Bleeding$1,300
Surgical Termination — by Gestational Week
≤ 12 weeks$850
121/7–123/7$900
124/7–126/7$940
13 weeks$950
131/7–133/7$1,000
134/7–136/7$1,040
14 weeks$1,050
141/7–143/7$1,100
144/7–146/7$1,150
15 weeks (unique circumstances)$1,200
16 weeks (unique circumstances)$1,300
Patients under 10 weeks requesting surgery$950
If you do not move forward with the pregnancy termination after your consultation and ultrasound, you remain responsible for payment of services received: $275 consultation + $290 ultrasound = $565.00 total.
Step 8 of 11

2026 Office Policies

Please initial each policy to confirm you've read and understood it.

Insurance Policies & Payments

All payments are due at the time of service. Our office is not contracted with most insurance and does not accept insurance fee schedules. Fee schedules are based on 120–150% of Medicare rates.

Labs & Testing

We are not contracted with insurance for office visits/procedures. We can bill your insurance for outside lab processing, but we are not responsible for any bill you receive from the lab.

Communications with Patient

By supplying my phone number, I understand I may receive calls or text reminders. Text reminders are optional and I may opt out at any time.

Balances on Accounts

Your balance is due at your follow-up visit unless payment arrangements have been made with the office manager.

Notice of Privacy Practices

I acknowledge I have reviewed the Notice of Privacy Practices describing how my personal health information may be used and disclosed.

No Insurance Assignment for Abortion Services

All abortion services are paid by Cash, Debit, or Credit Card only. We do not bill or accept insurance assignment for abortion services.

Missed Appointment Policy

Cancelling with less than 24 hours' notice or a no-show applies a $70 charge ($150 for a surgical termination appointment). All fees must be paid before future services.

Credit / Debit Card Payments

A 3.99% fee applies to card payments. No fee for cash payments.

Cardholder Policy

The cardholder must be present for in-office card payments, or complete an online Credit Card Authorization Form with ID verification.

Contested Credit & Debit Card Policy

If a contested charge is disputed and we successfully defend the claim, a $250 fee applies and may be sent to collections if unpaid.

Prescription Refills

Refills require an account in good standing and approval from Dr. Anna Contomitros. Birth control refills over 3 months require a completed Annual Exam.

Collaboration Between Patients & Office Providers

We have zero tolerance for obscenities or verbal/physical violence. No weapons or unauthorized photos of staff and doctor are allowed in our office.

Step 9 of 11

Release of Records

If anyone calls on your behalf, we cannot discuss or disclose any information about you, your visit, or your test results unless they are listed below. You may also choose "No one."

Step 10 of 11

Consent to Use De-Identified Ultrasounds for Education

I consent to allow A-All Woman Care, dba Woman to Woman Gynecology LLC, to use my ultrasound images for educational purposes. All identifying information and Protected Health Information (PHI) will be removed before any educational use.

You may decline this consent without affecting your care in any way.

Step 11 of 11

Review & Submit

Please confirm the statement below to complete your intake packet.

✓

Thank you — your intake packet has been received.

Our care team will review your information before your visit. If anything is time-sensitive, please call us at (702) 531-5400.

A-All Woman Care · 7908 W. Sahara Ave, Las Vegas, NV 89117 · (702) 531-5400 · lvabortion.com