Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Period Delay *FemaleName *FirstLastWhat’s your date of birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Phone *WHICH 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 | TabsProvera 10mg | TabsUtovlan 5mg | TabsIMPORTANT 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.We 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 orderWhy 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 OtherDo 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)? *YesNoPeriod 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 aboveDo 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 theseOther than those already mentioned, do you have any other medical conditions, illnesses, hospital stays or past surgical procedures? *YesNoPlease tell me your height in CMs or Feet *Please tell me your weight in KGs or Lbs *We need your blood pressure reading within last 9 months *I don't knowNormal (less than 140/90)High (more than 140/90) you any | Are you a smoker? *YesI used to smokeNo I've never smokedPlease 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 aboveAre 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 OtherAre you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs? *YesNoDo you have any known allergies? *YesNoIs there anything else you think I should know? *YesNoPlease 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 agreeSelect pharmacy for collection *674 Coventry Road, Small Heath, Birmingham, B10 0UU105 Barton Street , Gloucester, GL1 4HR267 Dewsbury Road, Leeds, LS11 5HZ41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RWNationwide Delivery ServiceYesAny Message for Us OptionalPrivacy Policy *I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy PolicySubmit
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