Are you female and over the age of 18 years?

By female we mean your gender at birth

What Date And Time did you have unprotected sex?

If you are requesting emergency contraception for future use please state this instead of providing a date and time

Does any of the following apply to you?:

• Are taking any regular contraception?
• Do you have a copper intrauterine device fitted?
• Are taking or have you taken Period delay medication in the last 7 days?
• Have you given birth within the last 3 weeks?
• Have you taken the emergency contraceptive pill in the last 7 days or since your last period?
• Do you have a history of ectopic pregnancy (where the baby develops somewhere outside the womb)
• Was your last period late, lighter/shorter or unusual in any way?

Have you had other episodes of unprotected sex earlier in this cycle?

Are you over 70kg (11 Stone) in weight AND/OR Do you have a BMI above 26kg/m2?

Work out your BMI on the NHS website 

Have you experienced an allergic reaction to either Levonorgestrel, EllaOne or any of their ingredients before? Or have any other allergies we should be aware of?

Are you currently taking any medication, including any antibiotics, over-the-counter medication, prescription medication issued by your doctor or herbal remedies?

Do you suffer from any of the following?:

• Bowel/digestive diseases (e. g. Crohn’s Disease)
• Severe liver problems?
• Any kidney problems?
• Severe Asthma treated with steroids?
• Epilepsy
• Salpingitis (inflammation of the Fallopian tubes)
• HIV
• Tuberculosis (TB)
• Acute porphyrias (metabolic condition)
• Lapp lactose deficiency, galactose intolerance or gluclose-galactose malabsorption)

Do you consent to the following?:

• The above questions have been answered truthfully and accurately and 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 I am requesting this treatment on my own free will
• I have read the patient information leaflet and will contact a medical professional if I have any questions or experience any unusual side effects while taking the 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 and or pharmacist
• I should inform my own GP of the treatment I receive from e Shop Pharmacy so they can see a full and accurate picture of my health
• I understand if vomiting occurs within 3 hours of taking emergency contraception, another tablet should be taken immediately.
• Emergency contraception is not 100% effective and I may still become pregnant even after taking it.
• Emergency contraceptive medication may cause menstrual cycle disturbances which can sometimes lead to earlier or late periods
• I understand EllaOne is more effective than levonorgestrel/Levonelle. EllaOne can be taken up to 120 hours (5 days) after unprotected sex whereas Levonorgestrel/Levonelle can be taken up to 72 hours (3 days) after unprotected sex, however taking it sooner offers greater effectiveness and if for any reason I do not receive my order within the necessary time then I will seek medical advice myself
• I’ve read and accept the terms & conditions and privacy policy

If our Pharmacist needs to contact you about your order, do you consent to them contacting you by telephone?

We may still contact you by email if we have any questions about your order