Emergency Contraception Form | Poppintree Pharmacy

Order the Morning After Pill

Name: This medication is for my own use

Customers must collect the morning after pill in person.

Date of Birth:

This service is available to women over 17 years of age only. If you are under 17 then please call the pharmacy to talk through your options.

Medical Card Number:

Address: E-mail: Phone Number:

Current Day of Menstrual Cycle:

Select the approximate day of your current cycle. The first day of your last period is day one.

Time Since Unprotected Sex: Is there any chance you may already be pregnant before this episode of unprotected sex?

I have previously used emergency contraception during this cycle

Emergency contraception can be taken more than once during a cycle but your pharmacist needs to know this so they can select the most appropriate product for you.

I am currently breastfeedingOther Medications:

Some customers are on medication that could make the morning after pill less effective. Listing any other medications you are currently on above (if applicable) will help your pharmacist select the best emergency contraception option for you.

Illnesses, Conditions and Allergies:

If applicale, please list any illnesses, conditions or allergies you may suffer from above to assist your pharmacist with product selection.

Collection Date:

Signature: