Period Delay > Period Delay Request Period Delay Request EligibilityThis consultation is only suitable for women aged 18 years or over who wish to delay an upcoming period.Are you aged 18 or over? Yes No Treatment is only available to adults aged 18 years or over. ✕ Warning — Cannot Continue You must be 18 or over Period delay treatment can only be supplied to adults aged 18 years or over. Patient DetailsFull Name(Required)Enter your full legal name.Date of Birth(Required) DD slash MM slash YYYY Your date of birth is required to verify you are over 18 and eligible for treatment.Email Address(Required) We will use this email address to send consultation updates and treatment information.Phone(Required)A pharmacist may contact you if further clinical review is required.Address(Required) Street Address Address Line 2 City Post Code Period InformationWhen is your next period expected to start?(Required) DD slash MM slash YYYY Are your menstrual cycles usually regular?(Required) Yes No Pregnancy CheckAre you pregnant, breastfeeding, or possibly pregnant?(Required) Yes No Norethisterone must not be used during pregnancy. ✕ Warning — Cannot Continue Pregnancy risk Period delay treatment must not be used if you are pregnant or may be pregnant. Medical SafetyHave you ever had a blood clot, such as a DVT or pulmonary embolism?(Required) Yes No Hormone medicines may not be suitable if you have had blood clots. ✕ Warning — Cannot Continue Treatment not suitable Norethisterone may not be suitable if you have had a blood clot. Do you have liver disease or a history of liver problems?(Required) Yes No Some liver conditions may affect whether treatment is suitable. ✕ Warning — Cannot Continue Medical review required Your medical history will require pharmacist review before treatment can be approved. Have you had any unusual or unexplained vaginal bleeding?(Required) Yes No ✕ Warning — Cannot Continue Further assessment required Treatment may not be suitable until the cause of your bleeding has been assessed. A pharmacist will review your request. Medication and AllergiesDo you have any allergies to norethisterone or similar hormone medicines?(Required) Yes No This helps ensure the medication is safe for you. ✕ Warning — Cannot Continue Allergy risk This treatment may not be suitable if you are allergic to norethisterone. Are you currently taking any prescribed or regular medication?(Required) Yes No This helps us check for potential medication interactions.List your regular medication(Required)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 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. Providing incorrect information may affect treatment suitability.Period Delay Consultation Consent(Required) I consent to this consultationI consent to the pharmacy reviewing my information to assess whether norethisterone is appropriate and safe to supply.Privacy Policy(Required) I agree to the Privacy PolicyPlease review how we collect, use and protect your personal data.CAPTCHA What to expect Complete this consultation so our pharmacist can review your details and confirm whether treatment is suitable for you.Confirmation email sent after submissionReviewed by our pharmacistOutcome and next steps sent by email Next steps 1Complete the period delay consultation 2Check your email for confirmation 3Our pharmacist reviews your information 4We email the outcome and next steps