What we treat
Men's Health
Erectile Dysfunction
Premature Ejaculation
Hair Loss
Women's Health
Period Delay
Combined Pill
Mini Pill
Alternatives to the pill
General Health
Asthma
Migraine
Acid Reflux
Weight Loss
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Period Delay
Do you believe you have the capacity to make decisions about your own healthcare?
Yes
No
Have you been diagnosed with any medical conditions?
Yes
No
Please provide more information, including diagnosis, symptoms and treatment.
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Yes
No
Do you suffer from any allergies?
Yes
No
What allergies do you have and what are the symptoms you experience from an allergic reaction?
Is there anything else you would like to include for the prescriber?
Yes
No
Please provide further information:
Are you currently using regular contraception?
No
Yes, I use a combined pill/patch
Yes, I use a mini pill/implant/injection or coil
A better way of delaying your period is taking your combined pill pack or your contraceptive patches back to back without a seven day break. We do not advise taking period delay medication and your combined pill together. Please confirm you understand.
Yes
Which combined pill or patch are you currently using?
Using the mini pill, a contraceptive implant or a contraceptive injection and period delay medication together, can result in a higher risk of having side effects from the hormones such as blood clots.
Yes
Which mini pill, implant, injection or coil are you currently using?
Do you experience irregular bleeding or spotting between your periods?
Yes
No
Please provide more information regarding your irregular bleeding or spotting between periods.
Why are you requesting period delay medication?
Are you currently breastfeeding, pregnant or actively trying for a baby?
Yes
No
Please provide more information.
Have you ever had migraines?
Yes
No
Who diagnosed your migraines? How long have you had them?
Do you ever get severe headaches at the front/side of your head, with nausea/vomiting, increased sensitivity to light or sound?
Yes
No
How long have you been experiencing these? Have you seen a doctor about them?
Have you or anyone in your family ever had a blood clot (e.g. DVT or PE); or have you had major surgery in the last 3 weeks?
Yes
No
Have you ever suffered from any of the following: cancer, diabetes, epilepsy, kidney problems, liver problems, asthma
Yes
No
Please provide more information.
Do you smoke?
Yes
No
Has your blood pressure been checked in the last 12 months?
Yes
No
What was the reading?
Above 140/90
Below 140/90
Do you agree to the following?
You agree to our terms and conditions, privacy policy and acceptable use policy
You will read the Patient Information Leaflet supplied with your medication
The treatment is solely for your own use
You are aware you will be subject to a soft check to validate your identity via Yoti
You have answered all the above questions accurately and truthfully
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You will inform your GP of this purchase if appropriate
Yes
No
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