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Period Delay Form
Period Delay Form
Period Delay Form
Please Enter your Full name:
Please Enter your Date of Birth
Please Upload your picture ID for Verification
Select File
Please Enter Name of your GP
Please Enter the Full Address including Post code of your GP
Address Line 1
City
Post Code
I give consent to share details of this order with your GP?
I agree
Are you pregnant, planning pregnancy or is there any possibility that you could be pregnant?
Yes
No
Do you suffer from severe pruritus (itchy skin all over the body)?
Yes
No
Are you breast-feeding?
Yes
No
Do you have porphyria or jaundice?
Yes
No
Are you allergic to norethisterone or any other similar hormone medicines?
Yes
No
If yes, please describe more
Have you previously had severe pruritus or pemphigoid gestationis (an itchy rash) during pregnancy?
Yes
No
Do you or your family have any current or previous bleeding disorders? This includes (but is not limited to):
Deep vein thrombosis (DVT)
Pulmonary embolism
None of the above
Are you currently using any contraception?
Yes
No
If yes, please provide details
Have you ever suffered from vaginal bleeding in which no cause was found?
Yes
No
Do you have any eye problems?
Papilloedema
Retinal vascular lesions
None of the above
Do you have any liver problems?
Yes
No
If yes, please provide details
Do you have any kidney problems?
Yes
No
If yes, please provide details
Do you have any heart problems? This includes (but is not limited to):
Angina
Heart attack
None of the above
Do you have any of the following:
Migraines
Epilepsy
Asthma
None of the above
Do you have high cholesterol, or do you smoke?
Yes
No
Do you or your close family have any of the following:
Systemic lupus erythematosus
Severe obesity (BMI >30 kg/m2 )
Thromboembolism
Recurrent miscarriage
None of the above
Have you previously suffered from jaundice, chloasma or pre-eclamptic toxaemia (high blood pressure) during pregnancy?
Yes
No
Are you being treated with steroid hormones?
Yes
No
Have you recently undergone major surgery or major trauma?
Yes
No
Have you been immobile for a prolonged time (bed rest) or are you due to receive surgery?
Yes
No
If yes, please provide details
Do you have endometrial hyperplasia (thickening of uterus lining)?
Yes
No
Do you have any allergies?
Yes
No
If yes, please provide details
Have you been told by your doctor you have an intolerance to any sugars?
Yes
No
If yes, please provide details
Do you have diabetes?
Yes
No
If yes, please list any associated problems
Do you have a known or suspected cancer, or have you had cancer in the past (e.g. breast cancer)?
Yes
No
If yes, please provide details
Do you have severe depression, generalized anxiety disorder or any other psychiatric disorder?
Yes
No
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Yes
No
Do you have inflammation of your veins (superficial phlebitis) or varicose veins?
Yes
No
Why do you want to delay your period?
Please provide details of any recent or past medical history of note (e.g. other medical conditions that you have previously been treated for)
Please list all your current prescription medication including any medication you buy over the counter
Please Select your choice of treatment
Utovlan tablets
Submit
