Rxpress

emergency Contraception

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Choose from a range of treatments that are up to 98% effective in preventing pregnancy

Date of Birth (DD/MM/YYYY):

Age:

Full Name:

Home Address:

Email:

Telephone:

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

1. Is Levonorgestrel 1.5 mg tablets for your own use?
YesNo

2. Are you over 16 years of age?
YesNo

3. Have you had unprotected sex within the last 72 hours (3 days)?
YesNo

4. Have you had unprotected sex earlier in this cycle?
YesNo

5. Was your last period late, lighter/shorter or unusual in any way?
YesNo

6. Have you already used Levonorgestrel 1.5 mg tablets since your last period?
YesNo

7. Are you currently taking any other medicines including herbal remedies (e.g. St John’s Wort)?
YesNo

Please list any medicines you are currently taking:

8. Do you suffer from bowel/digestive diseases (e.g. Crohn’s Disease) or any liver problems?
YesNo

9. Have you experienced an allergic reaction to Levonorgestrel before?
YesNo

Do we have permission to access your medical records?
YesNo