Name: Ovranette - YourPharmacy
Availability: InStock

Consent & Agreement(Required)

By completing this consultation form you agree to the following:

You acknowledge you must meet the NHS contraceptive service guidelines and criteria.

You must provide your FULL LEGAL name.

You will provide accurate and honest answers to all the questions.

You must provide you most recent weight and height measurements along with most recent blood pressure reading.

I agree to these conditions

Free NHS Contraceptive service provided by YourPhamarcy.

What is your preferred contraceptive pill? (Include Dose too)(Required)

Please note we can only offer what is available on our website and either a combined pill or progesterone only pill.

Personal Details

First Name(Required)

Last Name(Required)

Date Of Birth(Required)

Email Address(Required)

NHS Number (if known)

Telephone Number(Required)

Address(Required)

Street Address Address Line 2 City Post Code Country

Have you had your blood pressure checked in the last 3 months?(Required)

Yes

Please provide your blood pressure reading (if known)

Are you pregnant or might be pregnant?(Required)

Yes

Do you have long periods of immobility?(Required)

Yes

Neurological Health

Do you suffer from migraines?(Required)

Yes

If so, do you experience visual symptoms or changes in sensation or muscle power on one side of your body?(Required)

Yes

If you suffer from migraines, did your first attack occur when you started taking your contraceptive pill?(Required)

Yes

Cancers

Do you have any past or current history of breast cancer?(Required)

Yes

Do you have any undiagnosed breast symptoms?(Required)

Yes

Do you have any family history of breast cancer under the age of 50?(Required)

Yes

Do you have any past or current history of any other cancer?(Required)

Yes

Please Specify(Required)

What is your ethnicity?(Required)

Do you consent for us to share this with your GP?(Required)

Yes

This is recommended so they can keep accurate records.

Pharmacy First Sore Throat Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy's Terms and Conditions and Privacy Policy.

Important Information

You must not complete this consultation if you are experiencing any of the following

If any of these apply you must call 999 immediately

Difficulty breathing or swallowing.

Breathing that sounds abnormal or high-pitched.

A muffled or hoarse voice drooling.

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111 immediately.

A weakened immune system

You are not producing as much urine as usual.

Feeling to unwell to care for yourself, for example simple tasks like washing or making food.

A fever with feeling generally weak, dizzy or excessively tired

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

How long have you had as sore throat?(Required)

Have you felt feverish in the past 24 hours?(Required)

Yes

Have you checked your temperature recently?(Required)

Yes

Please enter the reading below (°C)

Do you have a cough?(Required)

Yes

How long have you had the cough?(Required)

Do you have a blocked or runny nose?(Required)

Yes

Do you have a rash or does your skin feel rough, like sandpaper?(Required)

Yes

I'm not sure

Upload a Photo(Required)

Tips for taking a good photo

Make sure you have adequate lighting

Make sure the subject is clear and in focus.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

Do you have a condition or use any medications that cause you to have a weakened immune system?(Required)

For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV.

Yes

What is the cause of your weakened immune system?(Required)

Please select the statement that best suits your circumstance.(Required)

I am pregnant

I'm trying to conceive

I am breastfeeding

None of the above

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon - Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree

Christmas Delivery Schedule

NHS Contraceptive Service

Ovranette

Contraceptive Service - NHS

By completing this consultation form you agree to the following:

Free NHS Contraceptive service provided by YourPhamarcy.

Personal Details

Screening Questions

Cardiovascular Health

Neurological Health

Cancers

Gastro-Intestinal Health

Other Health Conditions

Pharmacy Info

Pharmacy First Sore Throat Consultation

Important Information

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