Morning after pill - Laois Pharmacy

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ellaOne

Morning After Pill

Please fill out the form below...

- Step 1 of 4

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Medical Card Number (if you do not have a medical card number you can leave this blank)

Time since your protected sex: *

under 72 hours
72 - 120 hours
over 120 hours

Is the medication for your use? *

Yes
No

Is their any chance you may have been pregnant before this episode of unprotected sex? *

Yes
No

Have you used any form of emergency contraception since your last period? *

Yes
No

If so, please list below:

Are you breastfeeding? *

Yes
No

Are you taking any other medication? *

Yes
No

If so, please list below:

Do you suffer for any illnesses, conditions or allergies? *

Yes
No

If so, please list below:

Contact Phone Number *

E-mail *

Confirm *

I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that Laois Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

Name

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