Completing this form before you arrive cuts your waiting time and means you won't need to fill in a paper consultation in the pharmacy. A pharmacist reviews every record, you may still need a short private conversation before the medicine can be supplied. There is no charge to submit this form; you pay in the pharmacy when you collect.
Emergency contraception is more effective the sooner it is taken. If you can't complete every question, leave it blank and submit, the pharmacist will finish the assessment with you.
All questions in this section are optional.
If ovulation may already have happened, the pharmacist will discuss the copper coil (IUD), which is the most effective option, and can refer you on.
All questions in this section are optional.
Known or suspected pregnancy?
Currently breastfeeding?
Affects which product the pharmacist can supply.
Taking any enzyme-inducing medicines (e.g. rifampicin, carbamazepine, phenytoin, St John's Wort, efavirenz)?
Already used ulipristal acetate (ellaOne) this cycle?
Currently using progesterone-containing contraception?
Any previous bad reaction to emergency contraception?
Weight 70 kg or above, or BMI 26 or above?
The pharmacist may discuss a different dose or a copper coil.
Was the sex non-consensual, or are you worried about your safety?
We can refer you confidentially to a SATU unit or Gardaí for support.
I have been advised on the use of emergency contraception, STIs and ongoing contraception, and I understand the advice given. I consent to this consultation record being retained in accordance with GDPR and PSI standards.