Request for Medication to Delay

Any medication can potentially have side effects. You need to be aware that the medication used to delay a period carries a small increased risk of blood clots. The risk is similar to the combined contraceptive pill. To help us know if the medication is appropriate for you we need some information. Please answer the questions below. You will also need to give us a recent weight (in kg) and blood pressure reading. You can have your blood pressure checked at the Pharmacy. Then return the form to the reception desk. The form will be checked. Please contact the surgery after 48 working hours to see if the medication has been issued. Usually it will be straightforward. Very occasionally we might need to see you or speak with you.

Name(Required)

First Last

Preferred Contact Number(Required)

Date of Birth(Required)

Today's Date(Required)

Height(Required)

Weight(Required)

Blood Pressure Reading (there are 2 numbers, we need both please): Optional

Date of blood pressure taken

Do you smoke?(Required)

Have you ever had blood clots in your legs (DVT) or lung (PE)?(Required)

Has anyone in your close family ever had clots in the legs or lungs?(Required)

Do you suffer from migraines?(Required)

Are you taking/using any contraception?(Required)

Have you ever had breast cancer?(Required)

Is there a chance you could be pregnant?(Required)

When is your period due (roughly)?(Required)

When does your holiday start?(Required)

How long are you away for? (i.e when will you be ready to have a period)(Required)

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Request for Medication to Delay

Request for Medication to Delay

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