Do you or have you ever had or been diagnosed with any of the following?

• Breast cancer
• Liver cancer
• Blood clot/thrombosis for example Deep vein thrombosis (DVT) or a Pulmonary embolism
• Diabetes
• Epilepsy
• High blood pressure
• Heart disease
• Stroke or cerebro-vascular disease
• Acute porphyria
• Chloasma (a yellowish-brown pigmentation patches on the skin)

Are you taking any Medications for the following conditions?

• Epilepsy
• Tuberculosis (e.g Rifampicin or Rifabutin)
• HIV infections (e.g. ritonavir, nelfinavir, nevirapine, efavirenz);
• Hepatitis C virus infection (e.g. boceprevir, telaprevir);
• Any other infectious disease (e.g. griseofulvin);
• High blood pressure in the blood vessels of the lungs (bosentan);
• Depressive moods (e.g. St. John’s Wort);
• Certain bacterial infections (e.g. clarithromycin, erythromycin);
• Fungal infections (e.g. ketoconazole, itraconazole, fluconazole);
• High blood pressure (hypertension), angina or certain heart rhythm disorders (e.g. diltiazem).

Are you taking any other medication, including over the counter medicine, herbal medicine or recreational drugs?

Do you consent to us contacting your GP?

• It is advised that you inform your GP of the treatment you may receive from us. You can request a letter from us to provide to your GP or alternatively we are happy to inform your GP providing we have your consent. If you consent to us contacting your GP, please select Yes, we will then contact you direct to ask for details of your GP. Otherwise select No.

Please consent to the following:

• The above questions have been answered truthfully and accurately to the best of my knowledge. I understand that any incorrect information may be detrimental to my health
• The medication is for my personal use only and should be used as directed by the prescriber
• I will read the patient information leaflet and contact a medical professional if I have any questions or experience any side effects while taking my medication
• All information provided will be handle in the strictest confidence in line with the GDPR regulations and I am happy for E Shop Pharmacy to collect and use the information I provide for the purposes of prescribing medicines and to provide treatment for my medical condition
• I am happy to be treated by the prescribers and health care professionals at E Shop Pharmacy and the final decision on whether to prescribe treatment will be with the prescriber
• I’ve read and accept the terms & conditions and privacy policy

Please agree to the following:

• I understand there have been reports of patients developing depression or depressed mood whilst on contraception medication. If I experience mood changes or depressive symptoms I agree to contact my doctor for further medical advice as soon as possible
• I am currently not pregnant or there is no possibility that I may be pregnant
• I will contact my doctor if I notice any possible signs of a blood clot; sudden, severe stomach ache or jaundice; or sudden or severe pain in the lower abdomen or stomach area; a lump in my breast; unusual or heavy vaginal bleeding or that I may be pregnant