Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Why are you requesting medication for period delay?
Are you currently using regular contraception?
Please provide more information
Do you experience irregular bleeding or spotting between your periods?
Could you please give us more information regarding your irregular bleeding or spotting between periods?
Are you currently pregnant, breastfeeding or actively trying to have a baby?
Could you please provide us with more information?
Have you ever had migraines?
Who diagnosed your migraines and how long have you had them?
Do you ever experience severe headaches at the front and or side of your head with nausea and vomiting that is worsened by light and sound?
How long have you been experiencing this and have you seen a doctor about it?
Have you or anyone in your family ever had a blood close (DVT or PE) or have you had major surgery in the last 3 weeks?
Have you ever suffered from any of the following conditions: Diabetes, Cancer, Kidney problems, epilepsy, liver problems or asthma?
Do you smoke?
Has your blood pressure been checked in the past year?
What was your reading?
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
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