Pharmacy Mini-Grant Application

Independent pharmacies in California are eligible to receive $2,000 to support the implementation of medication abortion dispensing services!

See application guide and mini-grant requirements here.

Please follow the application as directed and thank you for your commitment to expanding safe and effective medication abortion and comprehensive reproductive health services in California and beyond.

This transformative grant is made possible through the California Department of Health Care Access and Information.

**Applications will be reviewed and processed on a rolling basis.**

Point of Contact Information

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1. First and Last Name (Required.)

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2. Email (Required.)

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3. Cell Phone Number (not general pharmacy phone number; for grant admin only/will not be shared) (Required.)

Pharmacy Information

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4. Pharmacy Name (Required.)

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5. Pharmacy License Number (Required.)

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6. Pharmacy Address (Required.)

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7. Pharmacy Phone Number (for patients to call) (Required.)

Mini-Grant Requirements Status

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8. Is your pharmacy currently certified under the REMS program to dispense Mifepristone? (Required.)

Yes

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9. Did the designated representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? (Required.)

Yes

Name of designated representative

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10. Did your back-up representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? *

Yes

Name of back-up representative

All grant recipients will be listed on MedicationAbortionPharmacies.com to assist patients and prescribers in locating nearby participating pharmacies, unless you notify us that you opt-out.

By submitting this application, I commit to fulfilling all outlined requirements within three months and I commit to the pharmacy dispensing mifepristone and misoprostol to our community. I understand and agree to provide required documentation, upon request, to receive this grant.

Pharmacy Mini-Grant Application

Question Title

* 1. First and Last Name (Required.)

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* 2. Email (Required.)

Question Title

* 3. Cell Phone Number (not general pharmacy phone number; for grant admin only/will not be shared) (Required.)

Question Title

* 4. Pharmacy Name (Required.)

Question Title

* 5. Pharmacy License Number (Required.)

Question Title

* 6. Pharmacy Address (Required.)

Question Title

* 7. Pharmacy Phone Number (for patients to call) (Required.)

Question Title

* 8. Is your pharmacy currently certified under the REMS program to dispense Mifepristone? (Required.)

Question Title

* 9. Did the designated representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? (Required.)

Question Title

* 10. Did your back-up representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? *

1. First and Last Name (Required.)

2. Email (Required.)

3. Cell Phone Number (not general pharmacy phone number; for grant admin only/will not be shared) (Required.)

4. Pharmacy Name (Required.)

5. Pharmacy License Number (Required.)

6. Pharmacy Address (Required.)

7. Pharmacy Phone Number (for patients to call) (Required.)

8. Is your pharmacy currently certified under the REMS program to dispense Mifepristone? (Required.)

9. Did the designated representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? (Required.)

10. Did your back-up representative already complete the required Medication Abortion CE training provided by Birth Control Pharmacist? *