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Gender:

Date of birth

Medical Assessment

Are you female?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or may become pregnant or start breastfeeding whilst taking this medication?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Have you or a family member ever had a blood clot in arteries, veins or lungs (pulmonary embolism)?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you allergic to norethisterone, medroxyprogesterone acetate, other similar hormonal medicines or to any other ingredient it contains (e.g. lactose)?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you suffer or have you ever suffered from any of the following?

  • asthma;
  • obesity and/or diabetes;
  • any heart problems (such as angina, heart attack, high blood pressure);
  • jaundice and/or kidney problems;
  • active trophoblastic disease;
  • breast or genital tract cancer;
  • depression;
  • migraine headaches;
  • epilepsy;
  • liver problems;
  • irregular vaginal bleeding of unknown cause;
  • porphyria (inherited disorder of haemoglobin);
  • systemic lupus erythematosus (SLE);
  • any other chronic condition we should know about;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Does any of this apply to you?

  • you have had a serious injury or have major surgery;
  • you are unable to move for long periods of time (for example after an operation);
  • you have history of repeated miscarriage;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you taking any of the following?

  • anticoagulants (e.g. warfarin);
  • oral contraception;
  • epilepsy medicine (e.g. carbamazepine);
  • antibiotics to treat infection (e.g. rifampicin, co-trimoxazole);
  • antivirals for HIV treatment (e.g. ritonavir);
  • anticancer medicine;
  • herbal preparation containing St. John’s wort (Hypericum perforatum);
  • NSAIDs for treating pain and inflammation (ibuprofen, diclofenac, aspirin);
  • medicines for high blood pressure;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Are you taking any other medication not mentioned in the questions above?

Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Do you agree to the following?

  • taking period delay medication can slightly increases the risk of blood clots especially when you are overweight;
  • you will tell your doctor if you are going to have an operation while taking this medication;
  • the treatment is solely for your own use and you will use it for the purpose of period delay and not for any other condition;
  • you have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
  • you will inform your doctor about any unusual side effects;
  • you will read the patient information leaflet supplied with your medication;
  • you will not exceed the maximum daily dose of this medication ;
Error We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

Phone 0207 867 3932

Email email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

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