Patient DetailsFirst Name *Last Name *Street Address *CityCountyEircodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweEmail Address *Phone *Date of Birth *This service is open to women 18 years old and over. If you are under 18 please call any of our pharmacies to discuss your options (Note: under 18’s can still purchase the morning after pill from Stratus Healthcare Pharmacy, but must visit the Pharmacy first).Doctor's Name *Doctor's Address *Reason for requesting service *Unprotected SexMissed Contraceptive PillProblem with the contraceptive patchProblem with the contraceptive ringCondom FailureOtherIf other, please specify:Time since unprotected sex *0-24 hours24-48 hours48-72 hours72-120 hoursIs the Emergency Contraception for your own use? *YesNoHave you used Emergency Contraception since your last period? *YesNoHealth QuestionsWas your last period early or late? *EarlyLateWas your last period lighter or heavier than normal *YesNoAre you taking any medication at the moment? *Do you have liver disease? *YesNoDo you have any allergies to ingredients in Ramonna or EllaOne (Emergency Contraceptions) *YesNoe.g. levonorgestrel, ulipristal acetate, lactose, galactose, maize starch, povidone, colloidal anhydrous silica or magnesium stearateIf yes, please specify:Please confirm you have read the patient information & counselling prior to completing this form *Determining which Emergency Contraception to GiveEllaOne (Ulipristal) EligibilityDo you suffer from severe asthma? *YesNoAre you breastfeeding? *YesNoIf breastfeeding, you are advised to express and discard breast milk for 7 days following EllaOne intake.Ramonna (Levonorgestrel ) EligibilityAre you breastfeeding? *YesNoIf breastfeeding, you are advised to express and discard breast milk for 8 hours following Ramonna intake.Do you suffer from or have a history of any absorption issues e.g. Crohn's Disease, Inflammatory Bowel Syndrome, Vomiting and/or Diarrhoea? *YesNoIf yes, please specify:Do you suffer from or have a history of porphyria? *YesNoDo you suffer from or have a history of infections of the fallopian tubes? *YesNoHave you suffered from an ectopic pregnancy? *YesNoDo you have any personal or family history or have a known risk factor for thrombosis? *YesNoIf yes, please specify:DeclarationI hereby declare that the information provided is correct to the best of my knowledge. I have understood the counselling and information I have read on hormonal emergency contraception and I have been advised about appropriate follow up with my GP/family planning clinic. *I am aware that I will need to attend the pharmacy in person & talk to the pharmacist to collect my Emergency Contraception. I am aware that Stratus Healthcare Pharmacy will retain this form for a period of two years in line with Data Protection Requirements. *Payment Method *Please select an optionInstore Submit Form