Sexual health - free contraception form | Kent Community Health NHS Foundation Trust

You are now able to start and renew oral contraception from some local pharmacies for free and without an appointment.

View the list of pharmacies providing this service.

Online contraception is only available to people aged 16 years and over who live in Medway or East Kent.

Progestogen-only pill (mini-pill, POP)
Combined Hormonal Contraception (CHC), for example, pills/patch/ring
Contraception injection (Depo Provera / Sayana Press self-administered injection)

We need to ask you some health-related questions. All information that you provide is kept securely in line with all guidelines.

Your answers will be reviewed by a member of the team:

If you are starting or changing contraception you will be invited to attend a 15-minute face to face clinic appointment.
If you are requesting repeat contraception you will receive a text to say your medication is ready to collect form your chosen pharmacy.

Please be aware that due to a high volume of people requesting this service this can take anything up to two weeks.

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on East Kent 0300 790 0245 or Medway 0300 123 1678.

Please complete the personal information form below.

Personal information

Date of birth*

You must be over 16 to use this form.

Postcode*

Please enter your postcode so we can check if you are eligible for this service. If not, please contact your local service.

Name*

First name Surname

Address*

Address line 1 Address line 2 City County Postcode

Mobile number*

Email*

The information below is required for anonymous reporting for health planning. The information in reports cannot be linked to you as an individual and will only be shared for NHS monitoring and research purposes.

Ethnicity*

Other, please specify

Country of birth*

Gender*

Is your gender the same since birth?*

Sexual orientation

Do you need an interpreter at the face-to-face appointment?*

Yes
No

What language do you need?*

Type of contraception

Type of contraception*

Please choose whether you would like a prescription for

Combined hormonal contraception
Progesterone only contraception
Contraception injection (Depo Provera / Sayana Press self-administered injection)

Combined hormonal contraception - new or repeat supply?*

New or change of contraception
Repeat contraception

Progesterone only contraception - new or repeat supply?*

New or change of contraception
Repeat contraception

Contraception injection - new or repeat supply?*

New or change of contraception
Repeat contraception

Where did you get your last contraception from?*

Other, please specify*

Combined hormonal contraception*

Progesterone only contraception*

Contraception injection*

A nurse may contact you if we need more information, please be aware this could be from a 'private' number.

All medication is issued on the understanding that you have answered the health-related questions honestly, that it is for your use only and for contraceptive purposes.

We will let know you by text if we are unable to prescribe contraception for you at this time.

Consent*

I consent to key information being shared with the pharmacy of my choice in order for them to safely dispense my chosen contraception.

Progestogene only pill

Have you taken the progestogen only pill before?*

Yes
No

What is the name of the contraception you are using?*

What oral contraception (pills)?*

Have you ever been told by a healthcare professional that the progestogen only pill might not be suitable for you?*

Yes
No

Gynaecological and postnatal history

Have you been at risk of pregnancy in the last three months?*

You may have been at risk of pregnancy if:

- you have had sex without a reliable method of contraception
- you have missed pills or have not been using your current method of contraception perfectly
- you have recently suffered from excessive vomiting or diarrhoea
- you are taking hormonal contraception and an interacting medication (e.g. for HIV, TB, epilepsy, or the antibiotics rifampicin or rifabutin).

Yes
No

Have you had a ‘normal’ period or bleed in the last four weeks?*

By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.

Yes
No, not having periods is normal for me due to the method of contraception I use
No

Have you experienced any unusual vaginal bleeding in the last two years?*

By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.

Yes
No

Are you up to date with your smear test?*

Yes
No

Have you had any new sexual partners within the last three months?*

0
1
2 to 4
5+

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via or www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on Kent 0300 790 0245 or Medway 0300 123 1678.

Up next, questions about your health

Please read each question carefully. If you answer yes, you may be asked to provide some more information, please answer as fully as you can.

Once you complete your order, one of our clinicians will review your answers and before they prescribe, they may need to call you asking for more detail.

Are you currently taking any medication or herbal remedies?*

Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.

Yes
No

What medication or herbal remedies are you taking, and what conditions are you taking these for?*

Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?*

Yes
No

Are you allergic to any medications?*

This includes oestrogen and progestogen, the hormones in contraception. medroxyprogesterone acetate methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216) or sodium?

Yes
No

Please let us know what medication you are allergic to and what happens if you take it*

Are you allergic to any food or drink, such as lactose, soy, nuts etc?*

Yes
No

Please let us know what you are allergic to and what happens if you consume it. For people who are allergic to lactose, are you able to tolerate a small amount in tablets? For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment.*

Please also tell us if you are happy to proceed*

Yes
No

Up next, questions about your health and family history

Again, please read each question carefully and answer as fully as you can.

If you answer yes, you may be asked to provide some more information.

Once you complete your order, one of our clinicians will review your answers and before they prescribe, they may need to call you asking for more information.

Have you ever had thrombosis (blood clots), a stroke or a heart condition?*

Hormonal contraception can sometimes cause an increased risk of blood clots.

Yes
No

Have you ever had breast cancer or an undiagnosed breast lump?*

Hormonal contraceptives can sometimes cause an increased risk of breast cancer.

Yes
No

Have you ever had liver problems or jaundice (you do not need to tell us about newborn jaundice)?*

Some hormonal contraceptives may be unsuitable for people with serious liver conditions.

Yes
No

Have you ever had gastro-intestinal (bowel) or gallbladder problems?*

For example, gallstones, inflammatory bowel disease, weight loss surgery or haemolytic uraemic syndrome. Changes to your gut can prevent contraceptives from being effective or could cause other health complications.

Yes
No

What gastro problems do you have?*

Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?*

For example:

porphyria
systemic lupus erythematosus (SLE)
arterial disease
coeliac disease
treatment for a hormone dependant cancer (e.g. breast, ovary, uterine, cervical or endometrial)
functional ovarian cysts or complications in pregnancy (e.g. jaundice, ectopic pregnancy or trophoblastic disease).

Yes
No

What serious health issues have you had?*

Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?*

Yes
No

Alcohol use*

Are you currently or have you ever experienced any of the below?

Sexual assault
Domestic abuse
Mental health issues
I do not want to answer
This is not applicable to me

Would you like one of our clinicians to call you to discuss and offer additional support/advice?*

Yes
No (I am safe and have received or am receiving support with this from other services and do not require contact at present)

Are you currently taking any medication or herbal remedies?*

Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.

Yes
No

Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?*

Yes
No

Combined hormonal contraceptive

Please click the link for further information

Some of the advantages of the combined pill are:

it usually makes your bleeds regular, lighter and less painful
it gives you the choice not to have a monthly bleed
it may help with premenstrual symptoms
it reduces the risk of cancer of the ovary, uterus, and colon
it improves acne in some people
it may reduce menopausal symptoms
it may reduce the risk of recurrent endometriosis after surgery
it helps with problems associated with polycystic ovarian syndrome (PCOS).

There are some serious possible disadvantages and side effects:

you may get temporary side effects at first including headaches, nausea, breast tenderness and mood changes; if these don’t stop within a few months, changing the type of pill may help
small increase in the risk of blood clots
the pill may increase your blood pressure
the pill doesn’t protect you from sexually transmitted infections, so you may need to use condoms as well
breakthrough bleeding (unexpected vaginal bleeding on pill taking days) and spotting is common in the first few months of use.

Speak to GP/Nurse straight away if you have any of the following:

pain in the chest, including any sharp pain which is worse when you breathe in, breathlessness, or coughing up blood
painful swelling in your leg(s)
weakness, numbness, or bad ‘pins and needles’ in an arm or leg
unusual headaches or migraines that are worse than usual
sudden problems with your speech or eyesight.

If you develop any new conditions, tell your doctor or nurse so they can check it’s still safe for you to take the pill.

If you go into hospital for an operation or have an accident which affects the movement of your legs, tell the doctor you’re taking the combined pill. You may need to stop taking the pill or need other treatment to reduce the risk of developing thrombosis. There are other contraceptive methods you can use instead.

Consent*

Please tick to confirm you have read and understood the above and attached links regarding your chosen method of contraception.

We need to check that there is nothing in your medical history that might make it unsafe for you to use Combined Hormonal Contraception.

Combined contraception is available to women under 50 years of age.

Have you ever taken the combined pill before?*

Yes
No

Have you ever been told by a healthcare professional that a combined contraceptive (pill, patch or ring) might not be suitable for you?*

Yes
No

Please tell us more

What is the name of the contraception you are using?*

What oral contraception (pills)?*

Physical measurements

We want to help you understand the connection between blood pressure and taking combined hormonal contraceptives.

Blood pressure is the force that moves blood around your body. It is normally measured by a cuff around your upper arm.

Everybody’s blood pressure is different, and it can change (become high or low) without you noticing.

For some people, combined hormonal contraceptives (pill, patch and ring) can make their blood pressure higher. Unmanaged high blood pressure puts you at increased risk of stroke or heart attack. It is important to check your blood pressure before you start a combined method, after the first 3 months and once a year whilst you continue to use it.

Next, we will ask you about your recent blood pressure

What was your most recent blood pressure measurement?*

Your health may be at risk if you provide inaccurate answers, for some people, combined hormonal contraceptives can make their blood pressure higher. Unmanaged high blood pressure puts you at increased risk of stroke or heart attack. Please do not continue unless you are sure this is a true reading from within the last year. Getting a blood pressure reading is easy.

Systolic (Top number)	Diastolic (Bottom number)

What is your height (in centimetres)?*

We need your height to calculate your BMI (body mass index).

If you have a high BMI and you use a combined hormonal contraceptive (pill, patch or ring) then there is a significantly increased risk of you having a blood clot, stroke or pulmonary embolism.

If you know you have a BMI over 34, you may want to consider ordering the progestogen only pill or the contraceptive injection instead.

What is your weight (in kilograms)?*

We need your height to calculate your BMI (body mass index).

If you have a high BMI and you use a combined hormonal contraceptive (pill, patch or ring) then there is a significantly increased risk of you having a blood clot, stroke or pulmonary embolism.

If you know you have a BMI over 34, you may want to consider ordering the progestogen only pill or the contraceptive injection instead.

Gynaecological and postnatal history

Have you had a baby in the last two months?*

If you have recently had a baby and have other risk factors, combined contraceptives (pill, patch or ring) may not be suitable for you at this time. If this is the case, our clinicians will help you consider your options once they have reviewed your order.

Yes
No

Are you breastfeeding or chestfeeding?*

If you’re breastfeeding, pumping or chestfeeding, it can affect the type of contraception that is most suitable for you and your baby. So even if you’re only doing night or day feeds, or you’re mixed feeding, let us know.

Chestfeeding is another term for feeding a baby with milk from your chest. We use it here because we want to include trans and non-binary parents as well as anyone who prefers this term.

National guidelines support that there are no proven negative impacts on infant outcomes or contraceptive effectiveness of using combined hormonal contraceptives whilst breastfeeding, as long as you start taking it six weeks after giving birth and have no other risk factors.

Yes
No

Have you been at risk of pregnancy in the last three months?*

You may have been at risk of pregnancy if:

you have had sex without a reliable method of contraception
you have missed pills or have not been using your current method of contraception perfectly
you have recently suffered from excessive vomiting or diarrhoea
you are taking hormonal contraception and an interacting medication (for example, for HIV, TB, epilepsy, or the antibiotics rifampicin or rifabutin).

Yes
No

Please tell us more*

Have you had a ‘normal’ period or bleed in the last four weeks?*

By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.

Yes
No, not having periods is normal for me due to the method of contraception I use
No

Have you experienced any unusual vaginal bleeding in the last two years?*

By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.

Yes
No

Are you up to date with your smear test?*

The cervical screening programme recommends smear tests every three years for women aged 25-49 and every five years for women aged 50-64.

Yes
No

Have you had any new sexual partners within the last three months?*

0
1
2 to 4
5+

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via or www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on Kent 0300 790 0245 or Medway 0300 123 1678.

Up next, questions about your health you’re your family history

Again, please read each question carefully and answer as fully as you can.

If you answer yes, you may be asked to provide some more information.

Once you complete your order, one of our clinicians will review your answers and before they prescribe, they may need to text you asking for more information.

Do you have diabetes?*

Yes
No

Do you have limited mobility?*

There is a possibility of increased risk of blood clots if you are immobile for prolonged periods of time. For example, are you a wheelchair user, bed-bound or you will be undergoing major surgery with limited mobility during recovery.

Yes
No

Have you ever had a blood clot, stroke or mini-stroke, heart disease, heart attack, irregular heartbeat, high cholesterol or problems with your heart valves?*

This may include venous or arterial thrombosis, pulmonary embolism, transient ischaemic attacks (TIAs) or hypertension. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of blood clots.

Yes
No

Has anyone in your immediate family had a blood clot (thrombosis), pulmonary embolism (PE), stroke or heart attack under the age of 45, or been diagnosed with inherited high cholesterol or an inherited blood clotting disorder at any age?*

For example, a parent, grandparent, sibling or child, who has had blood clots, a stroke, heart disease or heart attack when they were under 45. Including venous or arterial thrombosis, pulmonary embolus, TIAs, hypertension or high cholesterol. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of blood clots.

Yes
No

Have you ever had breast cancer or an undiagnosed breast lump?*

Hormonal contraceptives can sometimes cause an increased risk of breast cancer.

Yes
No

Do you have two or more immediate relatives who have had breast cancer? Or are you a carrier of any genes that predispose you to breast cancer, specifically BRCA1 or 2?*

Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of breast cancer. Therefore, if you have a parent, grandparent, sister or child who has or has had breast cancer you may want to consider ordering the progestogen only pill or the contraceptive injection instead or think about having a coil fitted.

Yes
No

Have you ever suffered from migraines or severe headaches?*

This includes headaches or migraines with an aura. Auras are changes to your vision and/or pins and needles or numbness, they can occur before, during or after a headache. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of stroke, this risk is increased when someone experiences migraines with aura.

Yes
No

Please give us more information about your migraines*

When was your last migraine? Do you take any medication for migraines? Did they start before or after you started using a combined contraceptive? Do you see visual disturbances such as bright spots, prism or zig zag shaped lights? Do you notice speech difficulties, increased sensitivity to noise, vertigo (dizziness), tinnitus (ringing in your ears), pins and needles or numbness down the side of your face or spreading from your fingers up your arm? Do any of these symptoms begin within an hour of the headache starting?

Have you ever had an autoimmune disease such as systemic lupus erythematosus (SLE)?*

Yes
No

Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?*

For example: hypertriglyceridaemia rheumatoid arthritis porphyria hepatitis severe depression complications during pregnancy or after childbirth (such as chorea, pemphigoid gestationis, pruritus, trophoblastic disease or hyperprolactinaemia).

Yes
No

Medication and allergies

Are you currently taking any medication or herbal remedies?*

Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.

Yes
No

What medication or herbal remedies are you taking, and what conditions are you taking these for?*

Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?*

Yes
No

Please let us know what you are allergic to and what happens if you consume it*

For people who are allergic to lactose, are you able to tolerate a small amount in tablets?*

For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment. Please also tell us if you are happy to proceed.*

Yes
No
No soy allergy

Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?*

Combined hormonal contraceptives (pill, patch or ring) may increase the risk of heart disease for those who and are aged 34 or over.

Yes
No

If you used to smoke, vape, use e-cigarettes or use any other tobacco products including shisha pipes, when did you stop?*

Less than a year ago
More than a year ago

Alcohol use*

Are you currently or have you ever experienced any of the below?

Sexual assault
Domestic abuse
Mental health issues
I do not want to answer
This is not applicable to me

Would you like one of our clinicians to call you to discuss and offer additional support/advice?(*

Yes
No (I am safe and have received or am receiving support with this from other services and do not require contact at present)

Contraception injection (Depo Provera / Sayana Press self-administered injection)

Have you ever used the injectable contraceptive before?*

Yes
No

Has a healthcare professional ever shown you how to use self-injectable contraception?*

Yes
No

What is the name of the contraception you are using?*

What oral contraception (pills)?*

What was your most recent blood pressure measurement?*

Your health may be at risk if you provide inaccurate answers, for some people, combined hormonal contraceptives can make their blood pressure higher. Unmanaged high blood pressure puts you at increased risk of stroke or heart attack. Please do not continue unless you are sure this is a true reading from within the last year. Getting a blood pressure reading is easy.

Systolic (Top number)	Diastolic (Bottom number)

What is your height?*

We need to know this in order to calculate your BMI (body mass index). The injectable may not be as effective for those with a BMI over 34. If you have a BMI over 34, you will still be able to complete this order form, but before your contraception is prescribed, a clinician will call you to discuss.

What is your weight?*

We need to know this in order to calculate your BMI (body mass index). The injectable may not be as effective for those with a BMI over 34. If you have a BMI over 34, you will still be able to complete this order form, but before your contraception is prescribed, a clinician will call you to discuss.

Have you ever been diagnosed with high blood pressure?*

We need to know this as the injectable may cause adverse complications for those with high blood pressure. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, clinician will call you to discuss.

Yes
No

Gynaecological and post-natal history

Have you been at risk of pregnancy in the last three months?*

Yes
No

You may be at risk of pregnancy if you are: having sex without a reliable method of contraception; you have missed pills or have not been using your current method of contraception properly; you have recently suffered from excessive vomiting or diarrhoea; or you have recently changed your method of contraception. If you are concerned about your risk, please reply ‘Yes’ or text us for further support.

Have you had a ‘normal’ period or bleed in the last four weeks?*

By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.

Yes
No, not having periods is normal for me due to the method of contraception I use
No

Have you experienced any unusual vaginal bleeding in the last two years?*

By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.

Yes
No

Are you up to date with your smear test?*

Yes
No

There is a weak association between using the injectable contraceptive for five years or longer and abnormalities on cervical smear tests. The increased risk reduces after stopping the injection. If you use the injectable contraceptive then please stay up to date with your smear tests. The cervical screening programme recommends smear tests every three years for women aged 25 to 49 and every five years for women aged 50 to 64.

Have you had any new sexual partners within the last three months?

0
1
2 to 4
5+

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on 0300 790 0245 or 0300 123 1678.

Up next, questions about your health

Please read each question carefully. If you answer yes, you may be asked to provide some more information, please answer as fully as you can.

Once you complete your order, one of our clinicians will review your answers and before they prescribe, they may need to text you asking for more detail.

Are you currently taking any medication or herbal remedies?*

Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.

Yes
No

Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?*

Yes
No

Are you allergic to any medications?*

This includes oestrogen and progestogen, the hormones in contraception. medroxyprogesterone acetate methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216) or sodium? iWe need to know this as medroxyprogesteroneis an active ingredient in the injectable. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, a clinician will call you to discuss.

Yes
No

Please let us know what medication you are allergic to and what happens if you take it*

Are you allergic to any food or drink, such as lactose, soy, nuts etc?*

Yes
No

Please let us know what you are allergic to and what happens if you consume it*

For people who are allergic to lactose, are you able to tolerate a small amount in tablets?*

For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment. Please also tell us if you are happy to proceed?*

Yes
No
No soy allergy

Up next, questions about your health and family history

Again, please read each question carefully and answer as fully as you can.

If you answer yes, you may be asked to provide some more information.

Once you complete your order, one of our clinicians will review your answers and before they prescribe, they may need to text you asking for more data.

Have you ever had thrombosis (blood clots), a stroke or a heart condition (inc. angina or heart attack), irregular heartbeat, high cholesterol, transient ischaemic attacks or problems with your heart valves?*

We need to know this as the injectable can cause an increased risk of blood clots. Therefore, we need to know if you have had high cholesterol, blood clots, strokes, heart disease, problems with your heart valves or heart attacks - this may include venous or arterial thrombosis, pulmonary embolus, transient ischaemic attacks (TIAs) or hypertension. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed.

Yes
No

Have you ever had breast cancer or an undiagnosed breast lump?.*

We need to know this as the injectable can sometimes cause an increased risk of breast cancer. Therefore, if you have or have ever had breast cancer in the past it may be unsafe to use the injectable. We also need to know if you have an undiagnosed breast lump. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, an will contact you to discuss. Hormonal contraceptives can sometimes cause an increased risk of breast cancer.

Yes
No

Have you ever had liver problems or jaundice (you do not need to tell us about newborn jaundice)?*

Some hormonal contraceptives may be unsuitable for people with serious liver conditions. We need to know this as the injectable may not be as effective due to the breakdown of progestogen by your liver. We do need to know if you have experienced jaundice during pregnancy. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, an will call you to discuss.

Yes
No

Have you ever had gastro-intestinal (bowel) or gallbladder problems?*

For example, gallstones, inflammatory bowel disease, weight loss surgery or haemolytic uraemic syndrome. Changes to your gut can prevent contraceptives from being effective or could cause other health complications.

Yes
No

What gastro problems do you have?*

Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?*

For example:

porphyria
systemic lupus erythematosus (SLE)
arterial disease
coeliac disease
treatment for a hormone dependant cancer (e.g. breast, ovary, uterine, cervical or endometrial)
functional ovarian cysts or complications in pregnancy (e.g. jaundice, ectopic pregnancy or trophoblastic disease).

Yes
No

What serious health issues have you had?*

Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?*

Yes
No

If you used to smoke, vape or use e-cigarettes, when did you stop?

Less than 12 months ago
More than 12 months

Alcohol use*

Are you currently or have you ever experienced any of the below?*

Sexual assault
Domestic abuse
Mental health issues
I do not want to answer
This is not applicable to me

Would you like one of our clinicians to call you to discuss and offer additional support/advice?*

Yes
No (I am safe and have received or am receiving support with this from other services and do not require contact at present)

Pharmacy

Thank you for providing us with your health information.

This will be reviewed one of our team to check you are eligible for online contraception.

A nurse may contact you if we need more information, please be aware this could be from a 'private' number.

All medication is issued on the understanding that you have answered the health-related questions honestly, that it is for your use only and for contraceptive purposes.

We will let know you by text if we are unable to prescribe contraception for you at this time.

Consent*

I consent to key information being shared with the pharmacy of my choice in order for them to safely dispense my chosen contraception

Location*

Please select your location first. You'll then be able to choose a pharmacy near you.

Pharmacy in Ashford*