Oral Contraception Consultation - Bury Healthcare Online

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

Oral Contraception

Consultation

We’re Here Whenever You Need Us

Email

customerservice@buryhealthcareonline.co.uk

Contact Us

46 Walmersley Road,

Bury, BL9 6DP

0161 2221024

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