Period Delay

About your condition and treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Are you male or female?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

What is your D.O.B (dd/mm/yyyy)

The Agreement

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Are your menstrual cycles regular and are you able to approximately estimate when your periods are due?

Have you suffered with vaginal bleeding when you are not menstruating? (e.g. bleeding between your cycles)

Why do you wish to delay your period?

Going on holiday

Sporting event

Religious festival

Other

Are you currently pregnant, planning a pregnancy or breastfeeding?

Have you ever previously suffered with any blood clots or Deep vein thrombosis (DVT) in the past?

Have you ever previously been advised not to use any contraceptives by any healthcare professional?

Are you over 35 years of age and a smoker?

Have you ever been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Is there any other information you would like to share with our prescribing team?

Risk Assessment

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 65 - This treatment is for my use only - I have the capacity to make decisions about my own healthcare - I have understood all the questions and have answered this consultation truthfully and completely - I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health - I will read the patient information leaflet supplied with this medication - I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health - I have read, understood and agree with our Terms and Conditions

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Period Delay

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