Morning After Pill Consultation

Are you female and over the age of 18 years? *

We mean female gender at birth

Yes No

What Date And Roughly What Time did you have unprotected sex? *

Date

Time (approx.)

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *

Yes No

Please provide more details

Does any of the following apply to you? *

Please select any of the following that applies (You can select more than one option)

I am taking regular contraception I have a copper intrauterine device fitted I am taking or have taken Period delay medication in the last 7 days I have given birth within the last 3 weeks I have taken the emergency contraceptive pill in the last 7 days or since my last period I have a history of ectopic pregnancy (where the baby develops somewhere outside the womb) My last period was late, lighter/shorter or more unusual than normal None of the Above

Have you had other episodes of unprotected sex earlier in this cycle? *

Yes No

Have you experienced an allergic reaction to either Levonorgestrel, EllaOne or any of their ingredients before? Or have any other allergies we should be aware of? *

Yes No

If you have answered Yes, Please provide more details below

Are you pregnant or suspect that you may be pregnant? *

Yes No

Are you currently breastfeeding? *

Yes No

Are you currently taking any medication, including any antibiotics, over-the-counter medication, prescription medication issued by your doctor or herbal remedies? *

Yes No

Please provide more details

Regarding your medical conditions, do you have any of the following? *

Please select any of the following that applies (You can select more than one option)

I suffer from bowel/digestive diseases (e.g. Crohn's Disease) I have severe liver problems I have been diagnosed with kidney problems I have severe Asthma that is treated with steroids I suffer from Epilepsy I have Salpingitis (inflammation of the Fallopian tubes) I am HIV Positive I suffer from or have suffered from Tuberculosis (TB) I suffer from Acute porphyrias (metabolic condition) I suffer from at least one of the following: Lapp lactose deficiency, galactose intolerance or glucose-galactose malabsorption None of the Above

If our Pharmacist needs to contact you about your order, do you consent to them contacting you by telephone? *

We may still contact you by email if we have any questions about your order

Yes No

Before you continue

Please read the following statements:

These questions have been answered truthfully and accurately and to the best of my knowledge. I understand that any incorrect information may be detrimental to my health
The medication is for my personal use only and I am requesting this treatment on my own free will
I have or will read the patient information leaflet and will contact a medical professional if I have any questions or experience any unusual side effects while taking the medication
All information provided will be handled in the strictest confidence in line with the GDPR regulations and I am happy for Pharmacy to collect and use the information I provide for the purposes of prescribing medicines and to provide treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to prescribe treatment will be with the prescriber and or pharmacist
I should inform my own GP of the treatment I receive from Pharmacy so they have a full and accurate picture of my health
I understand if vomiting occurs within 3 hours of taking emergency contraception, another tablet should be taken immediately. Emergency contraception is not 100% effective and I may still become pregnant even after taking it. Emergency contraceptive medication may cause menstrual cycle disturbances which can sometimes lead to earlier or late periods
I understand EllaOne is more effective than levonorgestrel/Levonelle. EllaOne can be taken up to 120 hours (5 days) after unprotected sex whereas Levonorgestrel/Levonelle can be taken up to 72 hours (3 days) after unprotected sex, however taking it sooner offers greater effectiveness and if for any reason I do not receive my order within the necessary time then I will seek medical advice myself

I agree to all of the above statements