Ortho Evra Birth Control Patch Evaluation

First Name:

Last Name:

Address:

City, State, Zip Code:

Phone Number:

*E-mail Address:

How did you learn about our firm?

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How did you find our website?

When did you start using Ortho Evra? (mm/dd/yy)

When did you stop using Ortho Evra? (mm/dd/yy)

What other types of Birth Control have you used in the last 3 years?

Did you smoke while on the patch?

Yes    No

While using the patch, did your Doctor diagnose you with any of the following?

If other, please specify