Morning After Pill

Are you a female (from birth) aged 18 above and has not reached menopause? *

Are you ordering this treatment for future use? *

When did the unprotected sex happen? *

When was the first day of your last period? *

By proceeding, you confirm that you understand the following: *

• Emergency contraception is time-sensitive. Due to potential response delays or delivery failure, supply may occur outside the licensed therapeutic window, during which efficacy decreases with time.
• If immediate use of emergency contraception is required, you should seek treatment directly from your general practitioner, community pharmacy, or local sexual health clinic.
• Emergency contraception must not be taken outside the licensed window:
  • Levonorgestrel: within 72 hours (3 days) of unprotected sexual intercourse
  • Ulipristal acetate: within 120 hours (5 days) of unprotected sexual intercourse

Since your last period, have you had any episodes of unprotected sexual intercourse or contraceptive failure? *

Was your last period late, lighter/shorter or unusual in any way? *

Have you already used 'morning after pill' since your last period? *

Is there any possibility you are already pregnant (e.g. symptoms of heavy breasts, morning sickness) *

What is your height (m)? *

What is your weight (kg)? *

BMI *

Have you given birth in the last 21 days? *

In the last 5 days have you had an abortion, miscarriage, ectopic pregnancy, or a uterine evacuation for a molar pregnancy (trophoblastic disease)? *

Do you suffer from any of the following? *

• Crohn’s disease
• Severe liver problem
• History of ectopic pregnancy (where the baby develops somewhere outside the womb)
• History of salpingitis (inflammation of the fallopian tubes)
• Severe asthma treated by oral glucocorticoid
• Acute Porphyria
• Hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption

Are you taking any of the following medications?

• Barbiturates and other medicines used to treat epilepsy (for example, primidone, phenytoin, and carbamazepine).
• Medicines used to treat tuberculosis (for example, rifampicin, rifabutin).
• A treatment for HIV (ritonavir, efavirenz)
• A medicine used to treat fungal infections (griseofulvin)
• Herbal remedies containing St John’s wort (Hypericum perforatum)
• Cyclosporin
• Antacids, proton-pump inhibitors or H2-receptor antagonists

Are you breast feeding? *

Do you have any allergies to levonorgestrel, ulipristal acetate, or other ingredients in emergency contraception (such as lactose), or have you ever experienced an adverse reaction to emergency contraception in the past? *

I understand that my eligibility for future use of emergency contraception is based on the responses I have provided in this questionnaire. I confirm that at the time I take the medication, these answers remain true and that there is no possibility I am pregnant. *

I understand fitting a Copper Intrauterine Device (Cu-IUD) within five days of unprotected sex or within five days from the earliest estimated ovulation is the most effective method of emergency contraception. *

I understand the medication is not for the termination of a pregnancy. *

I understand unprotected sex at any time during my cycle can lead to pregnancy, the morning after pill should be taken as soon as possible after unprotected sex. *

I understand that emergency contraception may not prevent pregnancy if ovulation has already occurred. However, there is no evidence that it causes harm to the person or to a developing foetus. *

I understand that this medication is not intended for regular contraception, and I should consider using a long-term contraceptive method if I am not currently on one. I should avoid starting any regular hormonal contraception within 5 days of taking ulipristal. *

I understand the morning-after pill is not 100% effective. I should take a pregnancy test if my next period is more than 5-7 days late or if the bleeding is lighter than usual. *

I understand that this medication only provides protection for that episode of unprotected sex and does not provide ongoing contraceptive cover. If I am using the oral contraceptive pill or patch, I should continue my method as prescribed but also use condoms for the next 7 days. If I am not using hormonal contraception, I should use condoms until my next period and seek further contraceptive advice from my GP or Sexual and Reproductive Health Clinic. *

I understand due to the risk of ectopic pregnancy, I should seek prompt medical attention if I experience severe lower abdominal pain after taking the morning-after pill. *

I understand that the morning after pill may cause nausea or vomiting. If I vomit or experience severe diarrhoea within three hours of taking it, the medication may not have been absorbed properly, and I should contact my doctor or pharmacist immediately, a repeat dose may be required. *

I understand that the morning after pill may affect the timing of my next period, which could arrive earlier or later than expected. *

I understand that unprotected sex can increase my risk of sexually transmitted infections (STIs). Since STIs may not always cause symptoms, it is recommended that I have a test at least once a year, or whenever I have a new sexual partner. Testing is available through my GP or local sexual health (GUM) clinic. Chlamydia can be tested until 2 weeks after unprotected sex. *

I understand emergency contraception will not affect my fertility. *

Can we share this information with your General practitioner? *

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

To ensure your medication is prescribed safely, our clinical team may need to: *

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

By submitting your responses, you consent to this where clinically appropriate, and agree to upload a summary health record from your prescriber or pharmacist if required.

Do you agree to the following? *

• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about my own health

I confirm if the medication does not arrive 24 hours before the cease of the therapeutic window, you will need to seek treatment directly from your general practitioner, community pharmacy, or local sexual health clinic. *

Emergency contraception must not be taken outside the licensed window:

• o Levonorgestrel: within 72 hours (3 days) of unprotected sexual intercourse
• o Ulipristal acetate: within 120 hours (5 days) of unprotected sexual intercourse

I confirm if my health changes before taking the medicine, I must inform the pharmacist who supplied it so they can review and re-authorise its use *