0121 554 9944




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Please use the following format 00/00/0000

Male
Female
Transmale (Born a female)
Transfemale (Born a male)

If yes, please list them.

If yes, please list them.

If yes, please list them:

If yes, please provide details:


If yes, how often?

Daily
Weekly
Rarely
Never




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If yes, please specify:

If yes, please provide details (e.g., type of emergency contraception, any side effects experienced):



If yes, please describe:



If yes, please describe:

If yes, please specify:



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I have been informed about the potential side effects and interactions of the prescribed medication for Contraception.

I agree to consult with my healthcare provider before starting any new medication. I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed. 

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.I understand that my information will be kept confidential and used solely for the purpose of this assessment. 

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.I understand that providing false information may result in my order being cancelled and may have health implications.