Please enter your details below and submit information and we will be in touch.

    Is the medication for yourself?
    Do you have a medical card?
    Has there been any other episodes of UPSI since last period?
    Did previous period occur more than 4 weeks ago?
    Has emergency contraception been used previously in this cycle?
    Are you breastfeeding?
    Are you taking any other contraceptive method?
    Is patient taking any other medication? (Incl. OTC and Herbal products)
    Does patient have history of any gynaecological problems?
    Do you suffer from any illness, conditions or allergies?

    NEXT STEP?
    We will review the information and prepare for your consultation. If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out the consultation over the phone. Your medication will be ready for collection within 1 hour (during store opening hours). You will still need to come to the pharmacy yourself to collect the medication.

    CONTACT PHONE NUMBER
    By entering your phone number here you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)

    I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that the Pharmacies will retain this questionnaire for a period of two years in line with Data Protection Requirements