____Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.12345678910111213141516171819202122Period Delay *FemaleNextWhat’s your date of birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NextWHICH MEDICINE DO YOU PREFER? Ultimately it will be a joint decision between you and one of our clinicians on whether a particular medicine is appropriate. *Norethisterone 5mg | 30 TabsNorethisterone 5mg | 60 TabsNorethisterone 5mg | 90 TabsProvera 10mg | 30 TabsProvera 10mg | 60 TabsProvera 10mg | 90 TabsUtovlan 5mg | 30 TabsUtovlan 5mg | 60 TabsUtovlan 5mg | 90 TabsNextIMPORTANT INFO | We need to know your blood pressure. Please ensure you have this reading ready. Just like a traditional consultation we're going to ask you about your medical history and symptoms. Your answers will help us assess your suitability for treatment. Please answer all questions honestly and in full. If you have any problems understanding or answering a question please call or message us. *I understand the important information above.NextWe aim to review orders for period delay medication within 24 hours. Whilst we are often faster, your order may take up to 24 hours to process. We are unable to fast track specific orders. Please tick to confirm you understand *I understand and wish to proceed with my orderNextWhy do you wish to delay your period? *Sporting event, wedding, work meetingHoliday, festival or religious eventTo help manage bleeding that occurs outside my normal periodOtherWhy do you wish to delay your period? | IF OTHERNextDo you experience any abnormal or undiagnosed vaginal bleeding (that is bleeding other than your period, such as bleeding in between periods or bleeding after sex)? *YesNoNext medical pill period? Period delay tablets carry an increased risk of blood clots. Please let us know if you have ever had any of these: Please select all that apply *A blood clot in your legs or lungsA strokePorphyriaCurrent immobility e.g. broken leg in the last 3 monthsHeart problemsBeen given treatment for high blood pressureSickle cell disease (not sickle cell trait)Surgery (an operation) in the last 3 months or due in the next monthA close family member who had a blood clot in the legs or lungsNone of the aboveNextDo you have any of the following? Please select all that apply *AsthmaEpilepsy or suffer from seizuresCancerDiabetes or abnormal sugar levelsGallstonesMigraines or severe headachesLiver Disease or have had this in the pastNone of theseNextOther than those already mentioned, do you have any other medical conditions, illnesses, hospital stays or past surgical procedures? *YesNoNextPlease tell me your height in CMs or Feet *Please tell me your weight in KGs or Lbs *NextWhat is your blood pressure taken in the last 9 months? *I don't knowNormal (less than 140/90)High (more than 140/90)NextAre you a smoker? *YesI used to smokeNo I've never smokedNextPlease tick any of the following that apply to you: *I am pregnant or I could be pregnantI have had a baby in the last 6 weeksI am breast feedingNone of the aboveNextAre you currently using any form of hormonal contraception? *Combined pill/patchMini pillHormonal coil (Mirena)ImplantInjectionOtherNo I am not using hormonal contraceptionAre you currently using any form of hormonal contraception? | IF OTHERNextAre you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs? *YesNoNextYou've told me you don't take any medication at all. Is that right? *Correct - I'm not on any medicationNo, I forgot to tell you somethingNextDo you have any known allergies? *YesNoNextIs there anything else you think I should know? *YesNoNextI want to check your understanding. Please tell me: I should start this pill 3 days before my period is due to get the best effect *TrueFalseNextWould you like me to tell your GP about any care we provide? Ideally your GP should know about any medicines you’re taking. *YesNo (This won't affect our review of your order, but we would encourage you to tell your GP)NextPlease confirm: you understand the questions asked; have answered them honestly; any treatment is for you only. You should read our clinicians’ advice and also, the patient information leaflet that comes with any medication. You can message us if needed. *Please tick to confirm that you understand and agreeSubmit
