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60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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Emergency Contraception Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about emergency contraception on Patient.info?

    It is advised that you read up about emergency contraception.

    Yes

    No

    2. The date and time of when you last had unprotected sex:

    3. Are you taking any of the following medication?

    • Barbiturates, Primidone, Phenytoin, Carbemazepine (used predominantly to treat epilepsy)
    • Rifampicin or Rifabutin (usually for tuberculosis)
    • Ritonavir (for HIV infection)
    • Griseofulvin (for fungal infections)
    • Ciclosporin
    • Herbal remedies containing St John's Wort, Hypericum perforatum
    • Antacids and anti-ulcer medication
    These medications can potentially interact with Levonelle and ellaOne. Please see a doctor before taking the 'Morning after Pill'.

    Yes

    No

    4. Have you been diagnosed with any of the following?

    • Severe liver problems
    • Severe digestive problems e.g. Crohn's disease
    • Previous ectopic pregnancy, fallopian tube surgery or pelvic inflammatory disease
    Please see a doctor before taking the Morning after Pill. We are unable to supply Levonelle or ellaOne.

    Yes

    No

    5. Are you aware that 'morning after pills' are not 100% effective?

    • When taken in the first 3 days after intercourse, pregnancy rates are close to 1.5 in 100 (ellaOne) or 2 in 100 (Levonelle)
    • Levonelle can be taken up to 3 days and ellaOne up to 5 days after intercourse.
    Neither Levonelle nor ellaOne are 100% effective. You can change your answer and continue.

    Yes

    No

    6. Do you think you are already pregnant?

    • Levonelle and ellaOne will NOT terminate an existing pregnancy. There is no evidence they will harm an ongoing pregnancy
    ?Morning after Pills? will not end a pre-existing pregnancy. To obtain a standby Levonelle or ellaOne to take when not pregnant change answer to 'No' and continue.

    Yes

    No

    7. Are you aware Levonelle should NOT be ordered by women who are overwieght because it is less effective?

    • Levonelle should NOT be requested by women with a BMI of 30 or above.
    • EllaOne will be more effective and should be ordered instead.
    • You can change your answer and continue.

    Yes

    No

    8. Do you require Levonelle or ellaOne for immediate use now?

    • Morning after pills work best if taken early, delay can result in failure
    See a doctor or dispensing pharmacist to avoid delay. To obtain a standby Morning after Pill for future use change answer to 'No' and continue.

    Yes

    No

    9. Are you aware Levonelle and ellaOne should NOT both be taken in the same menstrual cycle (period)?

    • Take either Levonelle or ellaOne, NOT both
    • Levonelle and ellaOne should also NOT be taken more than once in the same cycle (period)
    Levonelle and ellaOne should NOT both taken in the same menstrual cycle (period). You can change your answer to 'Yes' and continue.

    Yes

    No

    10. What are your current medications, if any?

      11. Have you considered Long Acting Reversible Contraception?

        Yes

        No

        12. Do the following apply to you?

        • I will read the information leaflet supplied with my tablets
        • I am over 18
        • The tablets are for my own use
        We cannot supply medication unless these conditions apply

        Yes

        No

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