Morning After Pill

This online form will save you time on your visit to Our Pharmacy. If you request the pharmacist to call you, most of the consultation can occur by phone before you visit the store. Otherwise the pharmacist will have your form ready and they will have a private consultation with you in the store.

This takes a few minutes to complete.

Morning After Pill

Morning After Pill Form


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

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.

Is there any chance you may already be pregnant before this episode of unprotected sex?

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

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?

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?

Do you suffer from any illnesses, conditions or allergies?

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

Location

Lord Edward St, Ballycullenbeg, Mountmellick, Co. Laois, R32 R6CT

Registered With The Pharmaceutical Society of Ireland

LogoSancoInternet_IE_B-336

Mountmellick Local Pharmacy is PSI registered to supply non-perscription medicines over the internet. PSI Contact details, Telephone: 01 218 4000, Address: PSI House, Fenian Street, Dublin 2, Email Address: internetsupply@psi.ie

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