Name *

First Name

Last Name

Phone *

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Preferred Contact Method *

Email

Text

Date of Birth *

MM

DD

YYYY

Are you a new or returning patient? *

New Patient

Existing Patient of Dr. Cousins

Existing Patient of Sue Seibold-Simpson

Birth Control Options

What methods are you interested in? Check all that apply.

Birth control pills

“The Patch”

“The Ring”

IUDs, such as Liletta and Paragard

The three-month “shot”

Barrier methods, such as the diaphragm and cervical caps

Insurance *

NYS Medicaid/Medicaid Managed Care

Excellus/Blue Shield

Other Insurance

I do not have Insurance