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Gender:
Date of birth
Are you a female ordering for yourself?
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
Why do you require emergency contraception?
Have you had unprotected sex earlier in this cycle?
Can you please provide more details?
Was your last period late, lighter/shorter or unusual in any way?
Have you already used 'morning after pill' since your last period?
Are you allergic to levonorgestrel, ulipristal acetate or any other ingredient in emergency contraception (such as lactose)?
Are you breastfeeding?
Is there a possibility that you may already be pregnant?
Please state your height:
Please state your weight:
Do you suffer from any of the following?
Are you taking any of the following?
Can you please provide the name, dosage and the reason why you are taking that medication?
Are you taking any other medication not stated in the list above?
Do you understand and agree to the following?
Do you agree to the following?
Please tick the boxes to confirm the following:
Order before 15:00pm (Monday to Friday) for next day delivery
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