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.
Are you currently:
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.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you a female aged over 18 years old?
Why are you requesting this treatment?
If you have had unprotected sex, it is important to visit your local GP or pharmacist as soon as possible. Cloud Pharmacy provides this service as a precaution to keep at hand should unprotected sex occur.
When was the first day of your last period?
Have you taken Levonorgestrel or ellaOne in your current menstrual cycle?
Please provide more details.
These should not be taken in the same menstrual cycle (period) without consulting your own GP.
Have you previously taken a form of emergency contraception?
Have you had any side effects from taking emergency contraception?
Are you currently taking the pill or any other form of contraception?
Do you suffer from any of the following?
Do you agree to the following?
I understand that if I weigh 70kg or more and I am looking to purchase Levonorgestrel (Levonelle) then I must take 2 of these tablets for maximum efficacy
I understand that I am purchasing this medication as a precaution and not following an episode of unprotected sex
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:
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.
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