First Name

Last Name

Email

Phone

Are you currently a Pandia patient?
Yes
No

Are you currently employed?
Yes
No
Other

I would like financial assistance for:
$20 Doctors consult fee for birth control
Birth Control Pills - 1 month ($20)
Birth Control Pills - 3 months ($45)
Birth Control Pills - 6 months ($90)
Emergency contraception

Age

I currently live in:
California
Florida
Lousiana
Texas

Other state

Ethnicity (check all that apply)

White
Hispanic/Latinx
Black or African American
Native American
Pacific Islander
Asian
Other

Living Situation (location, dependents)

Why are you applying for need-based funding? (500 characters max)

Annual income

Do you have health insurance?
Yes
No

(Optional) Upload supporting documentation*

* Supporting documentation may be an active or expired MediCaid insurance card, your financial aid form for college, or any other documentation showing financial need. Pandia Health strives to but cannot provide all applicants with financial assistance. Funds are limited by donations submitted. Currently, Pandia can only serve those in the state of California, Florida, LA and Texas. Applicants outside of CA, FL, LA and TX will be considered when we provide service in your state - there is no expiration date on when financial assistance can be considered for any given candidate.