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info@profarmadirect.com
07425 899611

Emergency Contraception Consultation

If you have had unprotected sex within the last 3-5 days, we offer the emergency contraceptive pill to help prevent pregnancy when other forms of contraception have failed.

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

No

Do you suffer from any allergies?

If so, please provide more information

Yes

No

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

No

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

No

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Is this a repeat prescription?

Yes

No

Are you aware the copper intra-uterine device is the most effective emergency contraception?

It should be inserted into the womb as soon as possible after unprotected sex and can be used if you have already taken the oral contraceptive pill. Once inserted, it will work as a contraceptive in the future as well.

It can stay in place for several years and can be removed any time you do wish to become pregnant. If you want to consider a copper IUD, ACT NOW and contact your local sexual health services, family planning clinic or doctor.

If you wish to continue with oral emergency contraception click Yes.

Yes

No

Are you female?

Yes

No

Levonorgestrel (Levonelle) must be taken within 72 hours of unprotected intercourse and is ineffective outside of this time period. Do you understand this?

Yes

No

Are you currently pregnant?

Yes

No

Have you given birth in the last 21 days?

Yes

No

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

Yes

No

Do you have severe liver disease or impairment?

Yes

No

Do you have acute porphyria?

Yes

No

Do you have a severe digestive problem that causes malabsorption?

Yes

No

Do you have an allergy to levonorgestrel, any other progestogens or progestogen containing medications?

Yes

No

Are you taking oral steroids for severe asthma?

Yes

No

Are you taking any of the following drugs?

Carbamazepine
Eslicarbazepine
Fosphenytoin
Oxcarbazepine
Phenobarbital
Phenytoin
Primidone
Rufinamide
Topiramate
Rifabutin
Efavirenz
Nevirapine
Ritonavir
Rifampicin
St Johns Wort
Modafinil
Bosentan
Aprepitant
Lumacaftor

Yes

No

I am being supplied with the emergency contraceptive pill called Levonorgestrel.

Yes

No

I should take this medication within 72 hours of unprotected sex.

Yes

No

I cannot take this medication if, since the first day of my last period I have already taken emergency oral contraception.

Yes

No

I understand that Levonorgestrel will reduce the chances I get pregnant after unprotected sex, but it is not 100% effective at preventing pregnancy.

Yes

No

I understand it does not prevent pregnancy if I have unprotected sex after taking it and I should therefore use additional contraception or abstain from sex until my next period.

Yes

No

If I am significantly overweight, emergency contraceptive may not be as fully effective.

Yes

No

If my period is a week later than I was expecting after using levonorgestrel, I should have a pregnancy test and take action if this confirms a pregnancy. If the test is negative, and another week passes, I should repeat the pregnancy test and seek the help of my doctor as well.

Yes

No

If I vomit within 3 hours of taking the pill then it may not have absorbed into my system and I should seek the help of my doctor.

Yes

No

Emergency contraception is not as effective as regular contraception and if I am not using any regular contraception, I should seek the help and advice of contraceptive services.

Yes

No

Emergency contraception does not protect me from sexually transmitted infections.

Yes

No

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

Yes

No

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

0%

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

No

About Us

Profarma Direct is a cutting-edge online pharmacy that specialises in lifestyle medicine and personalised prescriptions.

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom
07425 899611
For Sales & Orders:
info@profarmadirect.com
For General Enquiry:
info@profarmadirect.com

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You can check our pharmacy details and registration status here. You can also see details of any Fitness to Practise decisions relating to a registrant.

GPhC Registration Number:

2076639

GPhC Registered Owner:

Profarma Direct Ltd

Superintendent Pharmacist:

Zakaria Jalgaonkar

GPhC Pharmacy Details:

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom

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