Locate Us:
2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
Navigation Menu
Close Menu
Home
Services
Compliments & Suggestions
GDPR & PRIVACY NOTICE
GDPR Patient Leaflet PRIVACY NOTICE
Close Menu

Missed Period 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 missed periods on Patient.info?

    It is advised that you read up about this.

    Yes

    No

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

      3. Have you been on contraception in the last year?

        Yes

        No

        4. Have you been sexually active since your last period?

          Yes

          No

          5. If you have been sexually active in the last month, have you carried out a pregnancy test?

            If you have been sexually active, please do a pregnancy test and then complete the rest of this form - to seek further help from the practice, this result is essential

            Yes

            No

            6. If you have taken a pregnancy test, was the result positive?

              If you would like to be referred to Kings College Antenatal Team, click here. Please proceed with the consultation if you would like to be referred to St Thomas' Hospital

              Yes

              No

              7. 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