Contraceptive Pill and Patch Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email *

Which contraceptive Prescription would you like to get? *

Are you using this medication currently? *

Yes No

Who prescribed this medication for you last time? *

DOCTOR ONLINE DOCTOR PHARMACY NEVER PRESCRIBED Other

If other, please specify:

Since how long you are using this medication? *

MORE THAN 12 MONTHS LESS THAN 12 MONTHS

Are your periods regular? Particularly your Last period. *

YES NO REGULARLY IRREGULAR MISSED PERIODS SIGNIFICANTLY IRREGULAR PERIODS Other

If other, please specify:

Are you experiencing any side effect on this medication? *

NO YES YES, I HAVE, please specify:

Please specify your side effects:

Are you using this medication other than its mentioned purpose? *

NO YES YES, I AM, please specify:

Please specify:

Has your or any other Doctor ever advised you not to use this medication? *

NO YES, I WAS, please specify:

Please specify:

Do you suffer with any irregular vaginal bleeding or discharge? *

NO YES, I HAVE, please specify:

Please specify:

Are you fully aware how to use this medication? *

Yes No, I DON'T KNOW

Have you experienced any diarrhea or vomiting since your last treatment on this medication? *

NO YES

Medical History

Please answer the following questions about your medical history

What is your age? *

Are you pregnant? *

YES NO

Are you planning to get pregnant within the next six months? *

NO YES

Are you breastfeeding? *

NO YES

Do you smoke? *

NO YES CASUAL SMOKER (Less than a pack a year)

Have you ever been diagnosed with blood clots? *

YES NO

Have you ever been diagnosed with any liver disease? *

NO YES, I HAVE, please specify:

Please specify:

Have you ever been diagnosed with cancer? *

NO YES, I HAVE, please specify:

Please specify:

Have you ever been diagnosed with high blood sugar or Diabetes? *

NO YES, I HAVE, please specify: Type 1 or Type 2

Please specify Type 1 or Type 2:

Have you ever been diagnosed with migraine or severe headaches? *

NO, I'VE NOT YES, I HAVE, please specify:

Please specify:

Do you have any past medical history of high blood pressure, heart disease or are you on any medication for that? *

NO YES

Have you ever got your Cervical Smear Test done? *

NO YES, I HAVE, please specify when and what was the result:

Please specify when and what was the result:

Family History & Additional Details

Please answer the following questions about your family history

Do you have any family history of cancer? *

NO YES, THERE IS, please specify:

Please specify:

Do you have any family history of stroke or brain haemorrhage or heart disease? *

NO YES, THERE IS, please specify:

Please specify:

Do you have any family history blood clots? *

NO YES, THERE IS, please specify:

Please specify:

Do you have any past medical or surgical history that you want to mention to our doctor? *

NO YES, I HAVE, please specify:

Please specify:

Are you on any regular medications? If yes please specify below. *

What is your height

What is your current weight?

Are you allergic to any medication or any other substance? *

NO YES, I AM, please specify:

Please specify your allergies:

With our new Covid19 rules have your prescription sent to a pharmacy of your choosing (place Pharmacy details below) *

I confirm that the answers I have provided for the above questions are true and accurate to the best of my knowledge. *

I CONFIRM I DO NOT CONFIRM

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Review your details and complete payment

Consultation Summary

Contraceptive Consultation Fee

GP Review + Prescription

€25.00

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Contraceptive Pill & Patch Consultation

Personal Information

Medical History

Family History & Additional Details

Checkout

Consultation Summary

Contraceptive Consultation Fee