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Period Delay
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Processing your request...
Intro
Medical
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What is your name
Do you believe that you have the capacity to make decisions about your own healthcare?
Yes
No
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Yes
No
Please provide more detail.
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Yes
No
Please provide more detail.
Do you suffer from any allergies?
Yes
No
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Yes
No
Please provide more detail.
Why are you requesting medication for period delay?
Are you currently using regular contraception?
No
Yes, i use a mini pill/implant/injection or coil.
Yes, i use the combined pill/patch
Do you experience irregular bleeding or spotting between your periods?
Yes
No
Could you please give us more information regarding your irregular bleeding or spotting between periods?
Are you currently pregnant, breastfeeding or actively trying to have a baby?
Yes
No
Could you please provide us with more information?
Have you ever had migraines?
Yes
No
Who diagnosed your migraines and how long have you had them?
Do you ever experience severe headaches at the front and or side of your head with nausea and vomiting that is worsened by light and sound?
Yes
No
How long have you been experiencing this and have you seen a doctor about it?
Have you or anyone in your family ever had a blood close (DVT or PE) or have you had major surgery in the last 3 weeks?
Yes
No
Could you please provide us with more information?
Have you ever suffered from any of the following conditions: Diabetes, Cancer, Kidney problems, epilepsy, liver problems or asthma?
Yes
No
Could you please provide us with more information?
Do you smoke?
Yes
No
Has your blood pressure been checked in the past year?
Yes
No
What was your reading?
Would you like us to notify your GP of the treatment you chose to order today?
Yes
No
GP Practice Name, GP Postcode, GP Telephone Number
GP Information
Please provide your GP surgery details.
Consent & Declarations
I confirm that my answers are true and accurate and that I have read and agree to the Terms and Conditions and Privacy Policy.
Its required to fill all details.
Do you agree to the following:
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate
Yes
No
Sorry we can't offer you this treatment, please contact your GP.
Submit Assessment
Please complete all required questions.
