The following items are blank or not valid and must be updated:
First Name
*
Last Name
*
Phone
*
e.g. 555-555-5555
Email
*
Have you had the birth control device Paragard implanted?
*
Yes
No
Did your Paragard device fracture, resulting in injuries or a surgery?
*
Yes
No
When would be a good time to call you?
--Select--
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm
Anytime
Central Time