Morning After Pill Consulatation Form

Patient Details

First Name *

Last Name *

Street Address *

City

County

Eircode

Country

Email 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 *

If other, please specify:

Time since unprotected sex *0-24 hours24-48 hours48-72 hours72-120 hours

Is the Emergency Contraception for your own use? *YesNo

Have you used Emergency Contraception since your last period? *YesNo

Health Questions

Was your last period early or late? *YesNo

Was your last period lighter or heavier than normal *YesNo

Are you taking any medication at the moment? *

Do you have liver disease? *YesNo

Do 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 stearate

If yes, please specify:

Please confirm you have read the patient information & counselling prior to completing this form *

Determining which Emergency Contraception to Give

EllaOne (Ulipristal) Eligibility

Do you suffer from severe asthma? *YesNo

Are you breastfeeding? *YesNoIf breastfeeding, you are advised to express and discard breast milk for 7 days following EllaOne intake.

Ramonna (Levonorgestrel ) Eligibility

Are 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? *YesNo

If yes, please specify:

Do you suffer from or have a history of porphyria? *YesNo

Do you suffer from or have a history of infections of the fallopian tubes? *YesNo

Have you suffered from an ectopic pregnancy? *YesNo

Do you have any personal or family history or have a known risk factor for thrombosis? *YesNo

If yes, please specify:

Declaration

I 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. *

Do you wish to pay online or instore? *

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