Morning After Pill Assessment - Westcliffe Pharmacy

Name

First

Last

Date of Birth:

Address:

Please include post code

GP Practice:

Phone Number:

The Morning after pill – There are two types of emergency contraception: Levonelle/Levonorgestrel and Ellone if you have preference for which pill you would should take, please choose below

Ellaone- should be taken within 120 hours (5 days) of unprotected sex
Levonelle- should be taken within 72 hours (3 days) of unprotected sex

When did you have unprotected sex? (please give us the exact date)

Why are you requesting emergency contraception?

Contraception was not used
I have just started contraception and it is not yet effective
I missed one or more of my contraceptive pills
Contraception failed (Condom broke)
Other

last medication

In the last 7 days have you taken other morning-after or hormone pills (this affects what we can give you now)?

Medical History- Do you have any of the following?

Please tick the box if any applies to you

Are you taking any of the following medication?

Antiepileptics – (such as Carbamazepine, Oxcarbazepine, Phenobarbital, Phenytoin, Topiramate)
Antivirals (such as Efavirenz, Ritonavir)
Rifampicin/rifabutin
St John’s Wort
Other anti-epileptics or TB treatment
None of the above

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

If yes, please list any medications bought over the counter

Have you had your blood pressure checked in the last 3 months?

Allergies- Do you have any known allergies?

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?

Do you have any blood clotting illnesses or abnormalities?

Have you ever been diagnosed with atrial fibrilation?

Have you been diagnosed with acute porphyria?

Consent- Do you agree to the following?

I agree to notify the clinic and my GP if I experience any side effects, begin taking any new medications, or if my health or medical conditions change while I am receiving treatment. I confirm that this medication is intended for my personal use only and will not be shared with anyone else. I declare that all information I have provided is complete, accurate, and truthful to the best of my knowledge. I understand that prescribing decisions are based on the information I provide, and that supplying inaccurate or incomplete information may put my health at risk. I acknowledge that treatment decisions are made in collaboration with my prescriber; however, the decision to prescribe medication ultimately rests with the prescriber.
I understand that Levonorgestrel works best when taken as soon as possible after unprotected sex, ideally within 12 hours and no later than 72 hours (3 days). As it is not completely effective, treatment should not be delayed. I understand that ellaOne should also be taken as soon as possible after unprotected sex, ideally within 24 hours and no later than 120 hours (5 days). As it is not completely effective, it should be taken without unnecessary delay. I understand that if I vomit within 3 hours of taking Levonorgestrel or ellaOne, I will need to obtain and take a replacement dose as soon as possible. I understand that emergency contraception may temporarily affect my menstrual cycle, meaning my next period could arrive earlier or later than expected. I understand that I should use a reliable barrier method of contraception until my next menstrual period to reduce the risk of pregnancy. I understand that if I am taking Levonorgestrel and already use a regular hormonal contraceptive, I can continue using my usual contraception as directed. I understand that if I take ellaOne, it may reduce the effectiveness of my regular hormonal contraception. I should continue my regular contraception but also use a reliable barrier method until my next period. I understand that I should seek urgent medical advice if I develop unusual or severe lower abdominal pain after taking emergency contraception. I understand that emergency contraception does not protect against sexually transmitted infections (STIs). If I develop symptoms such as pelvic pain, unusual vaginal discharge, a fever, or have any concerns, I should seek medical advice promptly. I understand that I should contact my GP if my next period is unusually light, heavy, short, delayed, or does not occur. If I am unsure whether I have had a normal period, I should take a pregnancy test at least 3 weeks after unprotected sex. If my period is more than 5 days late or is significantly lighter or heavier than usual, I should take a pregnancy test and contact my GP without delay. I understand that emergency contraception is intended for occasional use only and does not replace an effective long-term contraceptive method. I should speak to my GP about suitable ongoing contraception options.

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