Morning After Pill Consultation Form

By completing the online consultation form in advance, your pharmacist can have your completed form and medication ready and waiting for you when you arrive at the pharmacy.

First Name *

Last Name *

Street Address

Address Line 1

Address Line 2

County

Eircode

Country

The reason we ask for your address is that we need it to enter onto our Patient Medical Record (PMR) along with the supply of the morning after pill

Date Of Birth *

Medical Card Number

This service is open to women 18 years old and over. If you are under 18 please call any of our pharmacies to discuss your options (Note: under 18’s can still purchase the morning after pill from Q Heatlh Pharmacy, but must visit Q Health Pharmacy first).

ADDITIONAL INFORMATION

Time since unprotected sex.under 72 hrs72 -120 hrsover 120 hrs

Is the medication for your own use?YesNo

Is there any chance you may already be pregnant before this episode of unprotected sex?YesNo

Have you used any form of emergency contraception since your last period?YesNo

If so please list below:

Are you breastfeeding?YesNo

OTHER MEDICATION

Are you taking any other medication?YesNo

Do you suffer from any illnesses, conditions or allergies (if so please list below)?YesNo

If so please list below

Contact Phone Number *

Email Address *

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