Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Do you believe you have the capacity to make decisions about your own healthcare?

Why do you need emergency contraception?

What date and time did you have unprotected sex?

Are you pregnant, or is there any possibility that you may be pregnant?

Are you currently breast-feeding?

Have you ever had a reaction or allergy with the contraceptive pill or other hormonal medication?

Have you taken Levonelle or ellaOne in your current menstrual cycle?
Levonelle and ellaOne should NOT both be taken in the same menstrual cycle (period) without consulting a doctor or contraception specialist?

Are you taking any of the following medications?

• Barbiturates, Primidone, Phenytoin, fosphenytoin, Carbemazepine, oxcarbazepine, (used predominantly to treat epilepsy)
• Rifampicin or Rifabutin (tuberculosis)
• efavirenz, nevirapine or Ritonavir (for HIV infection)
• Griseofulvin (for fungal infections)
• Ciclosporin
• Herbal remedies containing St John's Wort, Hypericum perforatum
• Antacids and anti-ulcer medication

Have you been diagnosed with any of the following?

• Liver problems
• Digestive problems or gut absorption problems e.g. Crohn's disease
• Previous ectopic pregnancy, fallopian tube surgery or pelvic inflammatory disease
• Women with severe asthma treated by oral glucocorticoid
• Lactose intolerance

Is there a chance that you may already be pregnant?

• This could be indicated by changes or interruptions to your menstrual cycle.
• ellaOne will NOT terminate an existing pregnancy.

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

I am aware of the following:

• Levonelle is effective if it is taken within 72 hours of unprotected intercourse and EllaOne is most effective for up to 120 hours (5 days). It may be used between 72 and 96 hours after unprotected intercourse but efficacy decreases with time. If you require the morning after pill immediately you should realise that there may be a delay (depending on your chosen delivery option) before your emergency pill arrives. This means that you risk getting pregnant.
• If you need the morning after pill immediately you should visit your GP. Alternatively, you can go to your local pharmacy where you can purchase the morning pill over the counter.

Are you aware:

• If vomiting occurs within three hours of taking the tablet, another tablet should be taken immediately.
• After using emergency contraception it is recommended to use a barrier method (e.g. condom, diaphragm or cap) until the next menstrual period starts.
• That emergency contraceptive medications may cause menstrual cycle disturbances which can sometimes lead to earlier or late periods.
• If menstrual periods are delayed by more than 5 days or abnormal bleeding occurs at the expected date of menstrual periods or pregnancy is suspected for any other reason, a pregnancy test should be conducted.
• The use of emergency contraception does not replace the necessary precautions against sexually transmitted diseases. If you develop pelvic pain, experience any vaginal discharge or a high temperature after unprotected intercourse you must seek medical advice.
• Use of Levonelle 1500 does not contraindicate the continuation of regular hormonal contraception.
• That ellaone will reduce the effectiveness of the regular ‘pill’, if you wish to start or continue using hormonal contraception, you must use a reliable barrier method until the next menstrual period.
• ellaOne may have minor or moderate influence on the ability to drive or use machines

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.