Oral ContraceptionConsultationComplete this form in order to see what types of oral contraception treatments you are eligible for. Step 1/4: Start Leave this field blank Answer these questions to get the most effective clinically proven treatments for you. Full Name Date of Birth Email Please provide an email address so we can contact you furhter regarding enquiries Phone Nunber Gender at Birth Male Female Sorry you are not eligible for this product Have you taken any emergency contraceptive pill before? Yes No Please provide further details Have you had unprotected sex? Yes No Please provide further details Was this the first time you had unprotected sex since your last period? Yes No Please provide further details Do you suffer from any type of liver disease? Yes No Do you suffer from any form of bowel disease such as ulcerative colitis or Crohn's disease? Yes No Do you suffer from asthma? Yes No Do you suffer from galactose intolerance, lapp lactace deficiency or glucose-galactose malabsorption? Yes No Have you had any allergic reaction to an emergency contraceptive pill in the past? Yes No Please provide further details Do you understand that no contraceptive pill is 100% effective. Yes No DO YOU AGREE AND CONSENT TO THE FOLLOWING? • I am over the age of 18 years and live in the UK.• I will familiarise myself with the patient information leaflet included with the medication.• I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP.• I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way.• I shall be the sole user of any medication offered to me through this service.• I confirm all answers are provided by me, and will be truthful. I agree to the terms and conditions Next
