NHS Morning After Pill

1. Please provide your details:

First Name *

Last Name *

Date of Birth *

Gender *

Email Address:

Postcode:

Phone Number:

Consent to Access Your Summary Care Records?

2. Are you pregnant, breastfeeding or trying to become pregnant?

Yes No

2b. Are you pregnant or breastfeeding? If you are pregnant how many weeks pregnant are you?

3. Why do you need emergency contraception?

Sex without contraception

Condom broke/ slipped off

Missed pill

Advance supply

Other

4. What date and time did you have unprotected sex?

ellaOne can be used up to 5 days (120 hours) after sexual intercourse, whereas Levonelle, or generic levonorgestrel, can be used up to 3 days (72 hours) after intercourse. The earlier it is taken, the more effective it is.

Date

Time

5. Are you currently taking the pill or any other form of contraception?

Regular contraception is more reliable than occasional use of emergency contraception. Coils, implants or injections are the most reliable. Contraceptive pills, patches, vaginal rings, caps or condoms are other reliable contraceptives.

Yes No

5b. Please provide more details:

6. Was your last period normal for you or was it abnormal (i.e. lighter, shorter or later than usual)?

Yes, my period was normal

No, my period was abnormal

I missed my period

I do not get periods

7. Have you been diagnosed with any of the following health problems?

Bowel or digestive disorders that’s causes malabsorption such as Crohn’s disease or ulcerative colitis
Liver disease
Prophyria
Ectopic pregnancy or had surgery to your fallopian tubes
Severe asthma treated with oral steroids

Yes No

7b. Please provide more details:

8. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

8b. Please provide more details:

9. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

9b. Please provide more details:

10. I can confirm that I have answered the questions to the best of my ability.

Yes No

10b. Please select a suitable date and time to book your appointment for a video consultation on the next page. If you feel you need your contraceptive pill more urgently, or your circumstances change, please seek more urgent review from your GP/Sexual health clinic.

We need to speak with you

We have gathered enough information

Please use the link below to go book an video call consultation about your conditions, please note we will be able to tell you more and answer any questions during the consultation.

Cancel

Name	Purpose	Expiry
CFID	This is a session cookie and is necessary for the operation of the site.	1 day
CFTOKEN	This is a session cookie and is necessary for the operation of the site.	1 day
SBCOOKIECONSENT	This cookie allows us to remember what choices you made relating to cookies you want to use on this site	1 year

Name	Purpose	Expiry
__UTMA	Used to distinguish users and sessions. The cookie is created when the javascript library executes and no existing __utma cookies exists. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMB	Used to determine new sessions/visits. The cookie is created when the javascript library executes and no existing __utmb cookies exists. The cookie is updated every time data is sent to Google Analytics.	30 mins from set
__UTMC	Set for interoperability with urchin.js. Historically, this cookie operated in conjunction with the __utmb cookie to determine whether the user was in a new session/visit.	When browser closed
__UTMT	Used to throttle request rate, used by Google Analytics	10 minutes
__UTMV	Used to store visitor-level custom variable data. This cookie is created when a developer uses the _setCustomVar method with a visitor level custom variable. This cookie was also used for the deprecated _setVar method. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMZ	Stores the traffic source or campaign that explains how the user reached your site. The cookie is created when the javascript library executes and is updated every time data is sent to Google Analytics.	6 months from set

NHS Morning After Pill

Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

13 Poplars Court,
Nottingham,
NG7 2RR

Opening times

Today’s Responsible Pharmacist

Medical History

Sign In