Assessment

Please provide your gender (at birth) This treatment is not suitable for males (at birth)

Have you had a blood pressure check-up with your GP/Nurse in the last 12 months?

What was your blood pressure result?

Do you experience any side-effects from the contraceptive pill?

Are you experiencing any unexplained or irregular bleeding?

Please enter your date of birth

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

Please provide more information below.

Are you up-to-date with your cervical smear tests? Smear tests are required every 3 years for women aged 25-49 and every 5 years for those between 50-64. You may require more regular smears if you have previously had an abnormal result.

Please provide your BMI result below.

How frequently do you smoke?

Have you been diagnosed with any of the following:

• High blood pressure, heart attack, angina, abnormal heart rhythm, impaired heart function
• Breast cancer or family or genetic risk of breast cancer
• Blood clot in leg or lungs
• Recent major surgery
• Thrombogenic mutations
• Family history of venous thromboembolism in first degree relative under age 45

Have you been diagnosed with any of the following:

• HIV or liver disease
• Diabetes or migraines
• SLE/ LUPUS/ GALLBLADDER DISEASE

Please provide more information below

Do you have any allergies?

Please provide more information

Do you have any medical conditions?

Please provide more information

I will ensure that I have regular blood pressure checks with my GP. Your blood pressure must be checked before you start any contraception, then again 6 months after you start and then annually.

I confirm that I am aware, I must have an annual pill review with my doctor.

I am aware this product is for female patients only, and that any orders for a male patient will be declined by our doctors.

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

Please enter your:

• Full Name
• Date of Birth
• Your registered home address with your GP

Please enter your:

• GP Surgery Name
• GP Surgery Address
• GP Surgery Email
• GP Surgery Contact Number

I confirm:

• I am over 18 years old
• The medicine ordered is for my sole use only
• I take responsibility to inform my own regular doctor of the online assessment or any changes in my circumstances
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages
• I have answered all the questions truthfully
• I agree to the Rightdose online pharmacy privacy policy and terms and conditions