Book Period Delay

Period Delay - Medical Assessment

If you have ordered this medication before, you can log in here to fill up the questionnaire automatically. Our pharmacists have a few quick and easy questions to help issue your FREE online prescription.

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Are you female?

Yes No

Health

Are you breastfeeding or pregnant or possibly pregnant?

Yes No

Do you have an allergy (hypersensitivity) to norethisterone?

Yes No

Do you or your family members have a history of deep vein thrombosis (DVT)?

Yes No

Have you been diagnosed with any of the following?

irregular vaginal bleeding of unknown cause
diabetes
depression
epilepsy, migraine, asthma, kidney or heart problems
transient ischaemic attack(TIA), stroke (please put below myocardial infarction (heart attack)
High blood pressure
Angina
Disorders that increase the risk of blood clots in the veins e.g. antiphospholipid syndrome, antithrombin deficiency or factor V Leidensystemic Lupus Erythematosus (SLE)
Rare hereditary disorders of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption.
Any liver disease or disturbance of liver function
jaundice or herpes during pregnancy
severe itching
porphyria (a rare metabolic disorder)
Dubin-Johnson Syndrome (chronic jaundice (yellowing of the skin or eyes)) or Rotor Syndrome (jaundice in childhood)
an inherited disorder of the red blood pigment haemoglobin (porphyria)
cancer of the breast or genital tract
any serious medical condition which may require immediate hospitalisation

Yes No

Medication

Are you taking any type of hormonal contraceptives (e.g. oral or injections)?

Yes No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Agreement

Do you understand that this medication should be only be used for delaying your period?

Yes No

Do you agree to the following?

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Period Delay - Medical Assessment

Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

Do you believe you have the capacity to make decisions about your own healthcare?

Are you female?

Are you breastfeeding or pregnant or possibly pregnant?

Do you have an allergy (hypersensitivity) to norethisterone?

Do you or your family members have a history of deep vein thrombosis (DVT)?

Have you been diagnosed with any of the following?

Are you taking any type of hormonal contraceptives (e.g. oral or injections)?

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Are you taking any of the following medications?

Do you understand that this medication should be only be used for delaying your period?

Do you agree to the following?