Emergency Contraception > Contraception Consultation Contraception Consultation Patient DetailsRequest a consultation with our pharmacist for contraception or emergency contraception. Complete the form and our team will review your details and confirm your appointment.Full Name(Required)Enter your full legal name.Date of Birth(Required) DD slash MM slash YYYY Required for pharmacy records.Email Address(Required) We will use this to confirm your appointment.Phone Number(Required)We may contact you to confirm your appointment.Address(Required) Street Address Address Line 2 City Post Code Service TypeWhat service do you require?(Required) Routine contraception Emergency contraception Emergency ContraceptionWhen did unprotected sex occur?(Required)Within 24 hours24–72 hours ago72–120 hours agoMore than 5 days ago ✕ Warning — Cannot Continue May not be suitable Emergency contraception may not be suitable after 120 hours. A pharmacist will review your request urgently. Have you already taken emergency contraception this cycle?(Required) Yes No Are you currently using hormonal contraception?(Required) Yes No Are you breastfeeding?(Required) Yes No Routine ContraceptionAre you currently using contraception?(Required) Yes No Which method are you currently usingCombined pillProgesterone-only pillPatchInjectionImplantCoil (IUD/IUS)OtherAre you requesting a repeat supply(Required) Yes No Do you have any concerns or side effectsOptional – include any concerns or side effects.Medical ScreeningDo you smoke?(Required) Yes No Do you have a history of any of the following?(Required) Blood clots Stroke Migraine with aura None of the above Are you pregnant or think you may be pregnant?(Required) Yes No ! Warning — Please Read Please be aware before continuing This service may not be suitable during pregnancy. A pharmacist will review your request. Do you have any medication allergies?(Required) Yes No List your allergies(Required)List any medication allergies.Appointment RequestPreferred Appointment Date(Required) DD slash MM slash YYYY Select your preferred date to visit the pharmacy.Preferred Time of Day(Required) Morning Afternoon Anytime GP Details and ConsentGP Practice NameEnter the name of your GP surgery if known.GP Practice PostcodeEnter the postcode of your GP surgery if known.Consent to contact my GP if needed(Required) Yes No I consent to the pharmacy contacting my GP practice if needed to support my consultation or treatment review. ! Warning — Please Read GP notification recommended We recommend informing your GP for continuity of care. A clinician may discuss this with you. DeclarationsInformation Accuracy(Required) I confirm my information is accuratePlease ensure all details are correct before submitting.Contraception Consultation Consent(Required) I consent to this consultationI consent to the pharmacy reviewing my information to provide advice and treatment where appropriate.Privacy Policy(Required) I agree to the Privacy PolicyPlease review how we collect, use and protect your personal data.CAPTCHA i Please Note Important information for your appointment Based on your answers, please bring your current medication list to your appointment. If anything changes before your visit, contact reception on 01785 258 181. What to expect Complete this confidential form so our pharmacist can assess whether emergency contraception is suitable and advise you on the next step.Confirmation email sent after submissionReviewed by our pharmacistPharmacy visit required if suitable Next steps 1Complete the confidential consultation 2Check your email for confirmation 3Our pharmacist reviews your answers 4Visit the pharmacy if treatment is suitable