Emergency Contraception Consultation

Time since unprotected sex:** Select 0–72 hours 72–120 hours Over 120 hours This information will help us choose the correct product. The sooner Emergency Contraception is taken after unprotected sex the more effective it is. There are products that can be taken up to 120 hours (5 days) after unprotected sex.

Current day of menstrual cycle Day one is the first day of your last period. If unknown, leave blank. This will help the pharmacist establish the risk of pregnancy.

Is this Emergency Contraception for your own use?** Select Yes No When collecting the morning after pill, customers must attend in person to the pharmacy.

Before this episode of unprotected sex, is there any chance you may have already been pregnant?* Select Yes No Don’t know

Are you Currently Taking any Medication* Select Yes No

Details of the medications you take regularly

Do you have any underlying health conditions* Select Yes No

Details of you condition