Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.

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Male
Female
Transmale (Born a female)
Transfemale (Born a male)


Yes
No
Occasionally


If yes, please specify.

Select all that apply.
Diabetes
High blood pressure
Heart disease
Blood clotting disorders
Liver disease
Kidney disease
Migraines with aura
Epilepsy
Any other long-term medical condition not listed





If yes, please provide details.

If yes, please provide details.



Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.

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If yes, did you experience any side effects?



If yes, please specify the type of contraception used:



Select all that apply.
Anticonvulsants (e.g., phenobarbital, phenytoin, carbamazepine)
Anti-infectives (e.g., rifampicin, rifabutin, tetracyclines, ampicillin, oxacillin, co-trimoxazole)
Ritonavir or nelfinavir
Herbal preparations containing St John's Wort
Aminoglutethimide
Ciclosporin
Anticoagulants
Griseofulvin
Selegiline
Tizanidine



Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

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  • I confirm that the information I have provided in this form is accurate to the best of my knowledge.
  • I understand that providing false or incomplete information may affect the safety of my treatment.

  • I understand that this treatment is for short-term period delay only and does not work as contraception.
  • I understand that norethisterone is a hormonal medication and may cause side effects.
  • I confirm that I do not have any medical conditions that would prevent me from safely taking this medication.

  • I agree to report any severe or prolonged side effects to my GP or pharmacist.
  • I understand that I must inform the pharmacist if I experience any unusual symptoms while taking norethisterone.
  • I understand that norethisterone may not be suitable for me if I am taking certain medications or have a history of specific medical conditions.

  • I am requesting norethisterone for the purpose of delaying my period.
  • I have had the opportunity to ask questions and understand the risks and benefits.
  • I understand that this medication should not be used regularly to manage my menstrual cycle.
  • I accept full responsibility for taking this medication as advised.