Contraception pill prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Which pill are you looking for? *

NORIDAY
OVRANETTE
OVREENA
QLAIRA
YASMIN
YASMINELLE
YAZ
ZOELY
FREEDO
VIOLITE
NUVARING
MARVIOL AZALIA
CERAZETTE
CILIQUE
EVRA PATCHES
ELVINA
ELVINETTE
LEONORE
LOGYNON
MERCILON
FREEDONEL
MINULET
MICROLITE

2. Please tell us why you are requesting the contraceptive pill? *

Renew prescription of existing contraceptive pill
First time using contraception
Want to try a different pill
Assist with bleeding (implant related)
Acne
Other

Can you please tell us your weight and height? *

Since you've never used a contraception pill before, we want to let you know that there are alternative contraceptives available that you don’t need to take every day. Kindly note that you need to visit a sexual health clinic or your GP to discuss options.Please tell us if you would like more information. *

Yes I understand and I want to start taking a contraception pill.
Please share more information with me

Please confirm your current pill and why you are looking to change it *

Please tell us when did you have the implant fitted. *

Less than 3 months
More than 3 months
More than 6 months

Since you fitted the implant, have you already been taking pills? *

Yes, and the bleeding has reduced
Yes but I still experience irregular bleeding
No

If you do not require contraception, please confirm that you have tried the gels and creams available for acne before you go on the pill. If you do need the pill for contraception, then we suggest a cream/gel be used aswell. Please enter our acne service if this applies to you. *

Yes, I have tried to use topic treatment for acne.
I've never used topic treatment for acne.

3. Please share with us your blood pressure taken in the last 6 months. Note that if you take the pill and have high blood pressure this can be dangerous, since it increases the risk of stroke and heart attack. *

It is high (140/190 or higher)
It is normal (less than 140/90)
I am unsure of my blood pressure / it was taken more than 6 months ago

You must ensure your blood pressure remains under 140/90 whilst you are taking the pill *

I understand this, and I know that I need to check this before I start taking the pill and have it checked every year
My blood pressure has not been checked, and I am not sure if it was under 140/190

Please obtain a reading of your blood pressure, and feel free to share with us, but without a blood pressure reading, we cannot prescribe this pill to you via our prescription service safely. *

I understand
I'm not interested anymore.

4. Are you a smoker? *

Yes
Not anymore
I've never been a smoker

Please confirm if you have any of the following, so that we can assess risks of a blood clot developing for you. *

Blood clots in your legs/lungs – Please share more information with us
Blood clotting issue such as lupus- Please share more information with us
A relative has a blood clot under 45 years old- Please share more information with us
You are immobile/using a wheelchair- Please share more information with us
You have had surgery In the last 2 weeks- Please share more information with us
These do not apply to me

When did you quit smoking ? *

Less then a year ago
More than a year ago

5. Please tell us if you have ever had any of the following? *

Heart condition
Breast cancer
High blood pressure
Diabetes
Stroke
Gallbladder problems
Liver problems
Any other condition

Please share more information with us *

6. Have you been experiencing any abnormal vaginal bleeding (bleeding other than your period such as after sex?) *

Do you know why you are experiencing abnormal bleeding *

Please share more information with us *

7. Do you currently suffer with severe headaches (migraines)? *

During your migraine episodes do you experience any other symptoms such as an aura or nausea? *

Yes
No
I am not sure, I need to share more information

Did your migraines get worse or begin when you started the pill? *

8. Have you given birth in the last 6 weeks? *

9. Are you breastfeeding? *

The pill should only be used once your baby is 6 weeks old and the evidence supports that there is no(?) effect on the baby. *

I understand, and will continue with my request
I am not sure, and would like to speak with someone further

10. Aside from what has already been shared, do you have any significant medical illness, conditions, stays in hospital or past surgical procedures? *

Please share more information with us *

11. Do you currently take any prescription medication, over the counter medication, recreational drugs that we have already asked you about? *

Please share more information with us *

12. Do you have any allergies? *

Please share more information with us *

13. Have you had a smear test? *

Yes- and I am up to date with my testing
Yes- and due to go for my next one soon
No- I am under 25 years old so this does not apply to me
No- I do not want to have a smear test

You're strongly advised to attend your NHS smear test, as this is crucial for reducing your risk of developing cervical cancer. *

I understand and I will contact my GP

14. Please confirm you understand that if you miss one of your pills can reduce the effectiveness of all oral contraception and it is possible you become pregnant. This way, if you believe you will struggle to remember to take your pill, please source another contraception method *

I understand and I want to continue with my request

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Contraception Pill