Name: Yasmin - YourPharmacy
Availability: InStock

YourPharmacy

Weight loss products are processed and dispatched within 2-3 working days.

Email Address

info@yourpharmacy.uk

Phone Number

0114 400 0181

Our Location

26 Greenhill Main Road

Home
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- Mounjaro®
- Wegovy®
Services
Men’s Health
Women’s Health
Travel Clinic
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Hayfever and Allergy

Book Online

Weight loss products are processed and dispatched within 2-3 working days.

Home
Weight Loss
- Mounjaro®
- Wegovy®
Services
Men’s Health
Women’s Health
Travel Clinic
Skin Care
Hayfever and Allergy

NHS Contraceptive Service

Yasmin

Free via the NHS Contraceptive service

Yasmin quantity

Contraceptive Service – NHS

This Form is for the free NHS contraceptive service provided by YourPharmacy.

Step 1 of 13

7%

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)

DD slash MM slash YYYY

Email Address(Required)

NHS Number (if known)

Telephone Number(Required)

Address(Required)

Street Address Address Line 2 City Post Code Country

Which of the these (if any) do you currently use for your contraception?(Required)

None

Injectable Contraception

Implant

Intrauterine Device (IUD)

Intrauterine System (IUS)

Vaginal Ring

Contraception Patch

Combined Pill

Progestogen Only Pill

Cap/Diaphragm

Spermicides

Natural Family Planning

Condom (Male)

Condom (Female)

Emergency contraception

Other

If other please specify(Required)

Please Specify more details.(Required)

Screening Questions

Are you wanting to start a new contraceptive pill or restart a previously used contraceptive pill?(Required)

Start a new contraceptive pill

Restart a previously used contraceptive pill

Continue current treatment plan with YourPharmacy

Have you previously had a supply of your contraceptive pill from your general practice, sexual health clinic or a pharmacy?(Required)

Yes

No

Are you wanting to change your current contraceptive pill?(Required)

Yes

No

Please Specify(Required)

Have you missed any pills at any point or had a gap of any duration since your last supply?(Required)

Yes

No

Please Specify(Required)

Have you had any problems with or side effects from your contraceptive pill?(Required)

Yes

No

Please Specify(Required)

Are you taking any other prescribed medication?(Required)

Yes

No

Please Specify(Required)

Are you taking any over the counter medicines or herbal products?(Required)

Yes

No

Please Specify(Required)

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

Yes

No

Please provide your blood pressure reading (if known)

Are you pregnant or might be pregnant?(Required)

Yes

No

Do you have long periods of immobility?(Required)

Yes

No

Cardiovascular Health

Are you a smoker (including vaping / use of e-cigarettes)?(Required)

Yes – I smoke Cigarettes

Yes – I use Vapes / e-cigarettes

No

If you are a smoker would you like help giving up?(Required)

Yes

No

What is your weight? (Include Units)(Required)

Whats is your height? (Include Units)(Required)

Do you have a current or past history of ischaemic heart disease, vascular disease, stroke, or transient ischaemic attack (TIA)?(Required)

Yes

No

Do you have diabetes?(Required)

Yes

No

Has this affected any of your organs (causing retinopathy, nephropathy, or neuropathy)?(Required)

Yes

No

Have you ever had a deep vein thrombosis or pulmonary embolus?(Required)

Yes

No

Do you have a current or past history of any heart disease?(Required)

Yes

No

Do you have parents, siblings or children who have had heart disease or strokes under the age of 45?(Required)

Yes

No

Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45?(Required)

Yes

No

Do you have any blood clotting illnesses / abnormalities?(Required)

Yes

No

Do you have any problems with your heart muscle or any impaired heart function?(Required)

Yes

No

Do you have or have you been diagnosed with atrial fibrillation?(Required)

Yes

No

Neurological Health

Do you suffer from migraines?(Required)

Yes

No

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

Yes

No

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

Yes

No

Cancers

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

Yes

No

Do you have any undiagnosed breast symptoms?(Required)

Yes

No

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

Yes

No

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

Yes

No

Please Specify(Required)

Gastro-Intestinal Health

Do you have any form of liver disease or liver impairment?(Required)

Yes

No

Do you have gall bladder disease that causes you symptoms or is medically managed?(Required)

Yes

No

Do you suffer from acute/active inflammatory bowel disease or Crohn’s disease?(Required)

Yes

No

Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?(Required)

Yes

No

Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid?(Required)

Yes

No

Other Health Conditions

Do you have any planned major surgeries?(Required)

Yes

No

Have you ever been diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus?(Required)

Yes

No

Have you ever had an organ transplant that has resulted in complications?(Required)

Yes

No

Do you have severe kidney impairment or acute renal failure?(Required)

Yes

No

Have you been diagnosed with Acute porphyria?(Required)

Yes

No

What is your ethnicity?(Required)

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

Yes

No

This is recommended so they can keep accurate records.

Pharmacy Info

Company Registration: 14116972
Premises GPhC Number: 9012029
Superintendent: Adil Amini (2083818)

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Contact

26 Greenhill Main Road, Sheffield, South Yorkshire, S8 7RD
0114 400 0181
Info@yourpharmacy.uk

Opening Hours

Mon – Fri: 09:00 to 17:00
Saturday: Closed
Sunday: Closed

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