Allcare Late Night Pharmacy Wilton

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Emergency Contraception (Morning After Pill)

Emergency Hormonal Contraceptive is free of charge for women 17y-35y old in possession of a PPS number. For all other women is 35€. Consultations are always free of charge. Fill in the form below. A pharmacist will contact you as soon as possible

Your Name

Adress

Email

Phone number

Date of Birth

PPS Number

Do you hold a medical card?

Yes

No

When did unprotected sex occur?

Less than 72 hours ago

Between 72h and 120h ago

More than 120h ago

Was any contraception used?

No

Condom

Contraceptive pill or ring or patch

long term contraception (Coil/injection/implant)

Was your last period normal?

Yes

No

N/A

Date of the start of your last period

Is this the first occasion of unprotected sex since your last period?

Yes

No

Have you emergency contraception before?

Yes

No

Last time you used emergency contraception?

Have you used emergency contraception more than twice in the last year?

Yes

No

Have you had any adverse reaction to emergency contraception in the past

Yes

No

N/A

List any medications you are taking (including contraception)

List any OTC medicines, supplements and herbal medicines you are taking

Do you have any digestive disorder, vomting, diarrhoea? If yes ,please explain.

Are you breastfeeding

Yes

No

Please note: the most effective emergency contraception is an intrauterine copper coil fitted by a doctor. If you want more information on this option, please ask the pharmacist

Ulipristal (Ellaone) is the most effective oral emergency contraception, unless you are currently on regular contraception.

I consent to keep record of this consultation

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