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Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You
Are you female and aged 18 years or over?
    We are unable to supply you with treatment. Please consult your GP.
    Please complete this question.
    Your Symptoms
    Do you understand that you must take this treatment within 72 hours (3 days) of unprotected sex?
      We are unable to supply you with treatment. If you have had unprotected sex within the last 120 hours (5 days), EllaOne would be a more suitable option for you.
      Please complete this question.
      Do you intend to use this medication more than once in the same menstrual cycle or if there is a chance you may already be pregnant?
        We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.
        Please complete this question.
        Do you understand that you should not take this treatment if you have had unprotected sexual intercourse more than once since your last period?
          We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.
          Please complete this question.
          Do you intend to take this treatment if your last period was late, light/shorter or unusual in any way?
            We are unable to supply you with treatment if there is any chance you may already be pregnant. Please consult your GP.
            Please complete this question.
            Your Health
            Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?
              We are unable to supply you with treatment. Please consult your GP.
              Please complete this question.
              Do you have an allergy (hypersensitivity) to levonorgestrel or any of its constituents including other hormonal contraceptives you may have used in the past?
                We are unable to supply you with treatment. Please consult your GP.
                Please complete this question.
                Have you been diagnosed with any of the following?
                • Past ectopic pregnancy
                • Severe bowel malabsorption disorders e.g. Crohns disease, ulcerative colitis or any others
                • Active trophoblastic disease
                • Acute porphyria
                • Fallopian tube surgery
                • Pelvic inflammatory disease
                • Liver problems
                • Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
                We are unable to supply you with treatment, please consult your GP.
                Please complete this question.
                Is your BMI greater than 26 (BMI calculator) or your weight greater than 70 kg?
                  Levonelle/ levonorgestrel may be less effective for women with weight >70 kg or BMI >26 kg/m. We cannot supply this medication and would recommend an alternative such as EllaOne or a copper IUD (intrauterine device). Alternatively, we recommend visiting your local pharmacy for further advice.
                  Please complete this question.
                  Your Medication
                  Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
                  Are you taking any of the following medications?
                  • Rifamycins – RIfabutin and Rifampicin
                  • Coumarins or Phenindione
                  • St Johns Wort
                  • Antiepileptics – Carbamazepine, Eslicarbazepine, Oxcarbazepine, Perampanel, Phenobarbital, Phenytoin, Primodone, Rufinamide, Topiramate, Barbituates
                  • Antivirals – Efavirenz, Nevirapine, Ritonavir
                  • Aprepitant
                  • Bosentan
                  • Cytotoxics – Rizotinib, Vemurafenib, Dabrafenib
                  • Ciclosporin
                  • Fosaprepitant
                  • Griseofulvin
                  • Lumacaftor
                  • Modafinil
                  • Selegiline
                  • Ulipristal
                  We are unable to supply you with treatment. Please consult your GP or doctor for more information.
                  Please complete this question.
                  Agreement
                  Are you aware the efficacy of levonorgestrel significantly decreases within the first three days, therefore do you agree to take it within 72 hours of sexual intercourse but preferably within 12 hours?
                    We are unable to supply you with treatment. Please consult our pharmacy team or your GP if you have any questions.
                    Please complete this question.
                    Do you understand the following?
                    • Levonorgestrel should be taken as soon as possible, preferably within 12 hours and no later than 72 hours (3 days) after you have had unprotected sex. Levonelle is not 100% effective so it should be taken at the earliest opportunity possible and must not be delayed.
                    • If vomiting occurs within 3 hours of taking levonorgestrel, you will need to take another dose immediately.
                    • Emergency contraception may cause menstrual cycle disturbances which means that your next period may be early or late.
                    • A barrier method of contraception needs to be used until your next period to prevent pregnancy.
                    • If you are already using a regular method of hormonal contraception, you can continue to take this as normal.
                    • You will need to seek medical attention promptly if any abnormal lower abdominal pain develops.
                    • Use of emergency contraception does not protect you against the risk of sexually transmitted diseases. If you develop pelvic pain, abnormal vaginal discharge, a high temperature or any other concerns about this, you must seek medical advice.
                    • You must see your GP in 3-4 weeks if your next period is abnormally light, heavy, brief or absent, or if you are concerned that the difference is not normal. If there is any doubt as to whether menstruation has occurred, a pregnancy test should be performed at least 3 weeks after unprotected intercourse. If your next period is more than 5 days late or is unusually light or heavy, you should perform a pregnancy test and contact your GP without delay.
                    • Emergency contraception is not a replacement for long term contraception. Please consult with your GP to discuss a reliable form of long term contraception.
                    You must agree to this before continuing. If you need assistance contact customer support.
                    Please complete this question.
                    Do you agree to the following?
                    • You will read the patient information leaflet supplied with your medication
                    • You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
                    • The treatment is solely for your own use
                    • You have answered all the above questions accurately and truthfully
                    • You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
                    • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber
                    You must agree to this before continuing. If you need assistance contact our customer support.
                    Please complete this question.
                    Complete our 2 minute questionnaire
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                    Ana Carolina Osorio De Faria Goncalves
                    To find a treatment suitable for you, we just need you to answer a few questions.
                    Ana Carolina Goncalves
                    Superintendent Pharmacist
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                    Need help?

                    If you need help with this medical assessment, contact our helpline:

                    0207 112 9014

                    or email us:

                    help@pharmica.co.uk
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