Emergency Contraception

Are you a female?

What is your D.O.B (dd/mm/yyyy)

What is your Height?

What is your weight?

Are you requesting Emergency contraception following unprotected sexual intercourse?

Did sexual intercourse occur within the last 72 hours?

Is there any chance you may already be pregnant?

This includes the following scenarios: - Did the unprotected sexual intercourse occur more than 5 days ago? - Is your period currently more than 7 days late? - Have you previously within this cycle had unprotected sexual intercourse without regular contraceptives?

Since your last period have you used emergency contraception (morning after pill)?

Have you ever been diagnosed with other medical conditions?

This includes but is not limited too things such as:
- Uncontrolled or severe asthma
- Crohn’s disease
- Rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption
- Liver problems

Please provide more details

Are you currently pregnant, planning a pregnancy or breastfeeding?

Do you suffer with any allergies?

If so, please provide more information

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so please provide details

Please provide more details

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

Please provide more details

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Emergency Contraception Consultation

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