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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Period Delay 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 delaying a period on Patient.info?

    It is advised that you read up about this.

    Yes

    No

    2. Please specify why you would like to delay your period:

      3. What was the start date of your last period?

        4. Are you allergic or sensitive to norethisterone?

          We are unable to supply norethisterone. Please consult your regular doctor.

          Yes

          No

          5. Are you pregnant or possibly pregnant?

          • Norethisterone is not recommended in pregnancy
          We are unable to supply norethisterone. Please consult your regular doctor.

          Yes

          No

          6. Are you taking contraceptive pills of any type?

            We are unable to supply norethisterone. Please consult your regular doctor.

            Yes

            No

            7. Are you using hormone injections for contraception?

              We are unable to supply norethisterone. Please consult your regular doctor.

              Yes

              No

              8. Have you had a thrombosis (DVT) or does thrombosis run in your family?

              • Also sometime called blood clots, usually in the calves of the legs.
              We are unable to supply norethisterone. Please consult your regular doctor.

              Yes

              No

              9. Are you over 35 AND a smoker?

                We cannot supply you with norethisterone. Women over 35 who smoke are at slightly higher risk of thrombosis.

                Yes

                No

                10. Do you have undiagnosed irregular vaginal bleeding

                  We are unable to supply norethisterone. Undiagnosed irregular vaginal bleeding requires investigation. Please consult your regular doctor.

                  Yes

                  No

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

                  • angina (heart pain)
                  • myocardial infarction (heart attack)
                  • high blood pressure
                  • liver disease
                  • jaundice in pregnancy
                  • severe itching or a severe blistering rash in pregnancy (rare)
                  • porphyria (rare metabolic disorder)
                  We are unable to supply norethisterone. Please consult your regular doctor.

                  Yes

                  No

                  12. Do all of the following apply to you?

                  • I will read the patient information leaflet supplied with my medication.
                  • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
                  The conditions must apply for you to be able to use this service.

                  Yes

                  No