Medical Assessment for Morning After Pill

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you female and aged 18 years or over?

Yes

We are unable to supply you with treatment. Please consult your GP.

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Your Symptoms

Do you understand that:

Levonelle/Levonorgestrel should be taken within 72 hours (3 days) of unprotected sex
ellaOne should be taken within 120 hours (5 days) of unprotected sex

Yes

We are unable to supply you with treatment. Please consult your GP.

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Do you intend to use this medication more than once in the same menstrual cycle or if there is a chance you may already be pregnant?

Yes

We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.

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Do you understand that you should not take this treatment if you have had unprotected sexual intercourse more than once since your last period?

Yes

We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.

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Do you intend to take this treatment if your last period was late, light/shorter or unusual in any way?

Yes

We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.

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Your Health

Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?

Yes

We are unable to supply you with treatment. Please consult your GP.

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Do you have an allergy (hypersensitivity) to levonorgestrel/Levonelle, ulipristal (ellaOne) or any of the constituents, including other hormonal contraceptives you may have used in the past?

Yes

We are unable to supply you with treatment, please consult your GP.

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Have you been diagnosed with any of the following?

Past ectopic pregnancy
Severe bowel malabsorption disorders e.g. Crohns disease, ulcerative colitis or any others
Active trophoblastic disease
Acute porphyria
Fallopian tube surgery
Pelvic inflammatory disease
Liver problems
Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption

Yes

We are unable to supply you with treatment, please consult your GP.

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Is your BMI greater than 26 (BMI calculator) or your weight greater than 70kg / 11st?

Yes

Levonelle/ levonorgestrel may be less effective for women with weight >70 kg or BMI >26 kg/m. We cannot supply this medication, but you may still be eligible for an alternative such as EllaOne or a copper IUD (intrauterine device). Alternatively, we recommend visiting your local pharmacy for further advice.

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EllaOne may be less effective for women with weight >85 kg or BMI >30 kg/m. We can still supply but would recommend an alternative method of emergency contraception such as a copper IUD (intrauterine device). Alternatively, we recommend visiting your local pharmacy for further advice.

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Your Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes

Are you taking any of the following medications?

Rifamycins – RIfabutin and Rifampicin
Coumarins or Phenindione
St Johns Wort
Antiepileptics – Carbamazepine, Eslicarbazepine, Oxcarbazepine, Perampanel, Phenobarbital, Phenytoin, Primodone, Rufinamide, Topiramate, Barbituates
Antivirals – Efavirenz, Nevirapine, Ritonavir
Aprepitant
Bosentan
Cytotoxics – Rizotinib, Vemurafenib, Dabrafenib
Ciclosporin
Fosaprepitant
Griseofulvin
Lumacaftor
Modafinil
Selegiline
Ulipristal

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

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Agreement

Are you aware and agree to the following:

The efficacy of levonorgestrel significantly decreases within the first three days, therefore do you agree to take it within 72 hours of sexual intercourse but preferably within 12 hours?
The efficacy of EllaOne significantly decreases within the first five days, therefore do you agree to take it within 120 hours of sexual intercourse but preferably within 24 hours?

Yes

We are unable to supply you with treatment. Please consult our pharmacy team or your GP if you have any questions.

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Do you understand the following?

Levonorgestrel should be taken as soon as possible, preferably within 12 hours and no later than 72 hours (3 days) after you have had unprotected sex. Levonelle is not 100% effective so it should be taken at the earliest opportunity possible and must not be delayed.
EllaOne should be taken as soon as possible, preferably within 24 hours and no later than 120 hours (5 days) after you have had unprotected sex. EllaOne is not 100% effective so it should be taken at the earliest opportunity possible and must not be delayed.
If vomiting occurs within 3 hours of taking levonorgestrel/ellaOne, you will need to take another dose immediately.
Emergency contraception may cause menstrual cycle disturbances which means that your next period may be early or late.
A barrier method of contraception needs to be used until your next period to prevent pregnancy.
If you are planning to take Levonorgestrel and are already using a regular method of hormonal contraception, you can continue to take hormonal contraception as normal.
If you are planning to take EllaOne, please be aware that EllaOne may reduce the effectiveness of your regular hormonal contraceptive. Therefore, whilst we recommend continuation of your regular hormonal contraception, you should use a reliable barrier method until your next menstrual period to prevent pregnancy.
You will need to seek medical attention promptly if any abnormal lower abdominal pain develops.
Use of emergency contraception does not protect you against the risk of sexually transmitted diseases. If you develop pelvic pain, abnormal vaginal discharge, a high temperature or any other concerns about this, you must seek medical advice.
You must see your GP in 3-4 weeks if your next period is abnormally light, heavy, brief or absent, or if you are concerned that the difference is not normal. If there is any doubt as to whether menstruation has occurred, a pregnancy test should be performed at least 3 weeks after unprotected intercourse. If your next period is more than 5 days late or is unusually light or heavy, you should perform a pregnancy test and contact your GP without delay.
Emergency contraception is not a replacement for long term contraception. Please consult with your GP to discuss a reliable form of long term contraception.

Yes

You must agree to this before continuing. If you need assistance contact customer support.

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Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance, please contact our customer support.

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Medical Assessment for Morning After Pill

To help us supply you with the most suitable treatment, please complete this online consultation.

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