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Period Delay

- tell us about your condition

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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?

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.

Please complete all required questions.

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We're rated excellent!

Your online consultation is reviewed by qualified prescribers before treatment is approved.

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Send an email to [email protected] if you need support before completing this consultation.

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