Your Name (required)

Your Address

This service is open to women over the age of 17 years old. If you are under 17 please call the pharmacy to discuss your options.

Your Date of Birth

Time since unprotected sex
0-72 hrs72-120 hrsover 120 hrs

ADDITIONAL INFORMATION
Current day of menstrual cycle? (The first day of your last period is day one).
This helps the pharmacist establish the risk of pregnancy. Leave blank if unknown.

First day of your last period

Is the medication for your own use? You must attend in person to collect the morning after pill.
YesNo

Is there any chance you may already be pregnant before this episode of unprotected sex?
YesNoDon't know

Will this be the first time you have used Emergency Contraception since your last period?
YesNo

Emergency contraception can be taken more than once in a cycle, but the pharmacist needs to know this, so they can select the most appropriate product.
Are you breastfeeding?
YesNo

Some might be on medication that could make the morning after pill less effective. The following questions help the pharmacist establish the best emergency contraception option for you:

Are you taking any medication, including any contraceptive methods?
YesNo

Do you suffer from any illnesses, conditions or allergies?
YesNo

WHAT HAPPENS NEXT?
Once you click submit, your chosen pharmacy will receive your details. The pharmacist will review the information and prepare for your consultation. If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out the consultation over the phone. Your medication will be ready for collection within 1 hour (during store opening hours). You will still need to come to the pharmacy yourself to collect the medication.

CONTACT PHONE NUMBER

By entering your phone number here you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)
Phone Number

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 Mountmellick local pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.