Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

Please confirm that you have seen your GP, practice nurse or specialist consultant to discuss hormonal contraception and they are happy for you to take it.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you pregnant, breast feeding, intending to become pregnant or given birth within the last 6 weeks?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Have you been prescribed this contraceptive before?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Was your last period late?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any family history of blood clots (including heart attacks) or breast cancer?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you currently experiencing any undiagnosed breathlessness or pains in your chest or pain/swelling in your calf?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you smoke?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Is your BMI more than 30kg/m²

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you fully mobile? 

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you aged over 35?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you attend your general practice on at least an annual basis to have a discussion about your ongoing use of the contraceptive pill? And if so do you commit to continue doing this?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you aware this method of contraception is not 100% reliable at preventing pregnancy even if taken correctly?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you aware of what to do if you forget to take your contraception as instructed? 

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Have you been diagnosed with any of the following? 

  • Heart or BP problems
  • Stroke
  • Thrombosis (blood clots)
  • Migraines
  • Breast or gynaecological cancer
  • Liver or Gallbladder problems
  • Undiagnosed vaginal bleeding

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Standard T&C

  • I will read the patient information leaflet supplied with my medication
  • I will contact my GP or MyMedsUK if I experience any side effects
  • The treatment is for my use only
  • I have answered the assessment questions truthfully and accurately
  • I agree to the Terms and Conditions and I confirm that I am over 18 years old
  • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

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