Emergency Contraception (Morning After Pill) Request Form This Emergency Hormonal Contraception (EHC) request is subject to consultation with the pharmacist. All information provided are private and confidential. Confidentiality can only be maintained as long as there are no considerations of harm. You can only make a request for yourself. Request on behalf of a different person other than yourself is not allowed. EHC is more effective the sooner it is taken—preferably within 12 hours. Please note that we are closed on weekends. Name * First Name Last Name Date of Birth * MM DD YYYY Are you over 16 years of age? * Yes No Address * Postcode * Phone / Mobile number * GP practice * The GP surgery you are registered with 1. Reason for requesting EHC (morning after pill) * No contraception used Failure of barrier method e.g. split condom Hormonal contraception failure e,g missed pills, drug interactions, sickness Vomited previous dose of EHC within 3 hours Recently expired injectable contraception 2. The date and time when unprotected sexual intercourse occurred * 3. What is the normal length of your menstrual cycle? * The length of the menstrual cycle varies from woman to woman, but the average is to have periods every 28 days. 4. When did you last had a period? * 5. Was your last period late, lighter/shorter or unusual in any way? * Yes No If yes, please specify 6. Have you taken EHC (morning after pill) before in the past? * Yes No 7. Have you already used EHC (morning after pill) since your last period? * If you have taken the morning after pill within this current cycle, please click yes. Yes No 8. Are you currently breast feeding? * Yes No 9. Are you currently taking any other medications? * Any medications including prescription medications, medication you bought from a pharmacy or any herbal preparations. Certain medications and herbal remedies may affect the effectiveness of emergency contraception pill. Yes No If yes, please specify 10. Have you experienced an allergic reaction to any hormonal pills, patches or injections before? * This includes reaction to any hormonal contraceptive pills you take regularly or you had before Yes No If yes, please specify 11. What is your current weight? * Please provide weight in either pounds or kilograms 12. What is your height * Please provide your height in either centimetre or feet and inches If your weight or BMI is above a certain range, you may need to take a double dose in order for the medication to be effective. User agreement: * I confirm that this request is for myself. I allow Pelican Pharmacy to access my medical information in order for the pharmacist to provide me with emergency hormonal contraception. Your request have been submitted. We will get back to you as soon as possible during our opening hours. Please note that we do not open on weekends.
