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Online Contraception / Birth Control Service

Please may you answer the following important questions. Any inaccurate or false information could potentially be dangerous to your health and safety:

Online Contraceptive Pill Service

First Name

Last Name

ID Number

Have you used birth control medication before?

Yes

No

What birth control method are you currently using and for how long have you been using it?

When was your last menstrual period?

Are your periods regular?

Yes

No

Do you experience any menstrual issues such as heavy bleeding or severe pain?

Nil

Heavy bleeding

Severe pain

Other

What are the other issues you may be experiencing?

Are you pregnant or breastfeeding?

What is your current weight in Kilograms (kg)?

What is your current height in Centimetres (cm)?

What is your latest blood pressure reading and when was it taken?

Do you smoke?

Yes

No

How many cigarettes do you smoke per day?

Do you have any of these conditions related to blood clotting?

Blood clotting disorder

Currently using or used blood clotting medication

Previous blood clots

Prolonged bed rest

Unable to move any limb

DVT (deep vein thrombosis)

None

Do you have a preference for a specific contraceptive?

I understand that providing false or inaccurate information could pose risks to my health and safety. I have provided truthful responses to all questions. This form is being completed solely to obtain a prescription for my personal use and not for anyone else.

Yes

Online Contraception / Birth Control Service

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