Period Delay Tablets consultation | Oxford Online Pharmacy

Please confirm that you understand that we do not prescribe norethisterone to patients aged over 35 due to the risk of blood clots.

Yes, I confirm

What is the reason you are ordering this medication?

Are you planning to travel abroad whilst taking this medication?

Yes

No

This question is required and must be answered.

Are you currently using any kind of hormonal contraception? For example: the combined pill, mini pill, coil, implant, patches or injection.

Yes

No

This question is required and must be answered.

Have you ever experienced any side effects while using a contraceptive tablet,ring or patch?

Yes

No

This question is required and must be answered.

Do any of the following apply to you:
You or someone in your close family has had a blood clot before
You have had major surgery in the last 6 weeks
or you are immobile?

Yes

No

This question is required and must be answered.

Do you have high or low blood pressure?

Yes

No

This question is required and must be answered.

Have you, or anyone in your family, ever suffered from thrombosis, breast cancer or cancer of the cervix, uterus or vagina?

Yes

No

This question is required and must be answered.

Do you suffer from migraines?

Yes

No

This question is required and must be answered.

What is your height and weight?

Height

Height in centimeters

Weight

Weight in kilograms

Do you take any medication, or have any medical conditions?

Yes

No

This question is required and must be answered.

Do you have any known allergies? E.g. Penicillin, egg protein or peanuts or an allergy to the ingredients in some medication eg lactose?

Yes

No

This question is required and must be answered.

Do you smoke any tobacco products or use a nicotine containing vape?

Yes

No

This question is required and must be answered.

Do you have any information or communication needs because of a disability (for example ADHD, ASD or Learning Difficulties), impairment or sensory loss that we should be aware of, in order to provide you with the best possible care?

This will help our clinicians and pharmacy team to allow you access all our services safely.

Yes

No

This question is required and must be answered.

Do you have any liver or kidney problems, including reduced kidney function or chronic liver disease?

Yes

No

This question is required and must be answered.

Have you ever had a heart attack or stroke?

Yes

No

This question is required and must be answered.

Are you breastfeeding or pregnant or planning to be pregnant?

Yes

No

This question is required and must be answered.

Do you have unexpected or unusual vaginal bleeding?

Yes

No

This question is required and must be answered.

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

No

Do you give us permission to inform your NHS surgery, about this prescription?

Yes

No

It is important to tell your doctor of any medication you have been prescribed for them to be able to treat you appropriately, safely and to avoid any drug interactions.

I am over 18 and this is for my sole use. I understand this is a non emergency service. I confirm I have answered all questions accurately and understand the doctor will use this information to prescribe safely for me.

Yes, I confirm

This question is required and must be answered.

By providing us with your details you confirm that you have read, understood and agreed to the legal terms and you consent to the sharing of your data to use our service.
I consent to treatment and an identity check
I give consent for the pharmacist to access and store relevant information from my NHS summary care record which may be needed to safely prescribe.
I agree to read the Patient Information Leaflet supplied with the medication.

Yes, I confirm

This question is required and must be answered.

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