Westcliffe Period Delay Tablets - Westcliffe Pharmacy

Name

First

Last

Date of Birth:

Address:

Please include post code

GP Practice:

Phone Number:

Email

What date is your next period due?

Is there any chance you could be pregnant?

Yes
No
I’m not sure

Have you ever been diagnosed with atrial fibrilation?

Yes
No

any Do Consent-

This treatment is not suitable for those using certain contraception. Please select the box if you are using any other the following methods of contraception.

We are unable to issue Period Delay treatment if you are taking and of the above.

Have you recently taken the morning-after pill?

Yes
No

Medical History- Do you have any or have you been diagnosed with any of the following?

Please tick the box if any applies to you

Do you Smoke?

Yes
No
Ex-Smoker

Do you take any other medication (other than prescribed by your GP)?

Yes
No

If yes, please list any medications bought over the counter

Do you suffer with High Blood Pressure?

Yes
No

Allergies- Do you have any known allergies?

Yes
No

If Yes, Please list any allergies below:

If you do not have a blood pressure monitor at home, you can get your BP checked at your nearest local pharmacy.

What is your Height and Weight?

Are you currently Breastfeeding?

Yes
No

Do you have any blood clotting illnesses or abnormalities?

Yes
No

Consent- Do you agree to the following?

I understand that this medication should be only be used for delaying my period
I agree to inform my GP if I experience any side effects, start taking any new medications, or if my medical conditions change during treatment. I confirm that this treatment is for my personal use only and will not be shared with anyone else. I confirm that I have answered all questions accurately, honestly, and to the best of my knowledge. I understand that the prescriber relies on the information I provide when making prescribing decisions, and that providing incorrect or incomplete information could put my health at risk. I understand that decisions about my treatment are made in partnership with the prescriber; however, the final decision on whether to issue a prescription rests solely with the prescriber.

Once you have completed and submitted the form, one of our clinicians will be in touch to confirm your new supply.