Book Emergency Hormonal contraception

Emergency Hormonal Contraception Consultation Form

This online form allows us to have your medication ready on your arrival saving you time in-store. Please complete the questions below. When you click submit, one of our pharmacists will review the information and contact you for a phone consultation. Your medication will then be ready for collection.

Name: *

Date of Birth: *

Address: *

Medical Card no. (if applicable)

If you have a Medical Card please enter your number here (Alternatively you can bring your medical card with you to the pharmacy):

PPS Number (Aged 17 to 35 years of age only)

If you are under 36 years of age you must provide a PPS number to avail of the Free Contraception Scheme:

Time since unprotected sex? *

This helps us to choose the correct product. One of the products can be taken up to 5 days (120 hours) after unprotected sex, but with all emergency contraceptives the sooner emergency contraception is taken the more effective it is.

0-24hrs

24-48 hrs

48-72hrs

72-96hrs

96-120hrs

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.

Is the medication for your own use? *

Unless isolating you must attend in person to collect the morning after pill

Yes

No

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

Yes

No

Don't Know

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 our Pharmacist needs to know this, so we can select the most appropriate product.

Yes

No

Are you breastfeeding? *

Yes

No

Some medicines can make the morning after pill less effective. The following questions help us establish the best emergency contraception option for you:...

Are you taking any medication, including any contraceptive methods and vitamins or supplements? *

Yes

No

If yes please specify:

Do you suffer from any illnesses or conditions? Or are you allergic to any medicines? *

Yes

No

If Yes, please list here:

Select a store: *

Do you want to complete a consultation over the phone?

By entering your phone number here you are consenting to our 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)

I confirm 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 Higgins Pharmacies will retain this questionnaire for a period of two years in line with Data Protection Requirements. *