Contraception V1

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What is your birth sex* This field is required.
Female
Male
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Personal infoPlease leave your information for prescription
First Name
Last Name
Address
Eircode
PPSN
Please enter your phone
3
Please leave your Email Address
example@example.com
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Date of Birth* This field is required.
Date
Day
Month
Year
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Are you currently using the treatment you have requested for 6 months or more* This field is required.
Yes
No
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What contraceptive would you like a prescription for?* This field is required.
Combined Contraceptive Pill (COCP)
Single Hormonal pill - Progesterone Only
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Please select the one that you need(COCP)
Please Select
Please Select
cilique ( norgestimate 250 micrograms & ethinylestradiol 35 micrograms)
elvina ( 0.03 mg ethinylestradiol & 3 mg drospirenone)
elvinette ( 0.02 mg ethinyl estradiol and 3 mg drospirenone)
evra patches ( 203 micrograms of NGMN and 33.9 micrograms of EE)
freedo ( 0.03 mg ethinylestradiol and 3 mg drospirenone)
freedonel ( 3 mg of drospirenone and 0.02 mg of ethinylestradiol)
leonore ( 100mcg levonorgestrel and 20mcg ethinyloestradiol)
logynon ( Levonorgestrel 50 micrograms and 30 micrograms Ethinylestradiol(or 125+30/75+40))
marviol ( desogestrel 150 microgram and ethinylestradiol 30 micrograms)
mercilon ( 20 micrograms of ethinylestradiol (an estrogen) and 150 micrograms of desogestrel (a progestogen) and 7 small white inactive tablets (first row of the strip))
microlite ( 20 mcg ethinyl estradiol and 100mcg levonorgestrel)
minulet ( 75 micrograms of gestodene and 30 micrograms of ethinyloestradiol )
nuvaring ( 11.7 mg etonogestrel and 2.7 mg ethinylestradiol)
ovranette ( 150 micrograms levonorgestrel and 30 micrograms ethinylestradiol)
ovreena ( 30 micrograms Ethinyloestradiol and 150 micrograms Levonorgestrel)
violite ( 100 micrograms of levonorgestrel and 20 micrograms of ethinylestradiol.)
yasmin ( 3 mg drospirenone and 0.030 mg ethinylestradiol.)
yasminelle ( 0.02 mg ethinylestradiol and 3 mg drospirenone)
yaz( 0.02mg/3mg ((Ethinyloestradiol 0.020 mg and drospirenone 3 mg))
Zoely 2.5 mg/1.5 mg film-coated tablets
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Please select the one that you need(Single Hormonal pill)
Please Select
Please Select
Noriday (Norethisterone 35microg)
Cerazette (Desogestrol 75microg)
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Please input your weight(kg)* This field is required.
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Please input your height(cm)* This field is required.
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Your BMI number:formula: weight(kg) / height(m) *2 ( overweight : >30kg/m2 >35kg/m2(obese)
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You are overweight. There are studies stating overweight women have higher risk of developing clot, myocardial infarction and stroke with combined contraceptive pill. Do you still want to continue?Click here for more information
Yes. I am willing to take risk despite the risks stated
No. I want to make consultation with GP
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You are obese(POP). There are studies stating obese women have higher risk of developing clot, myocardial infarction and stroke . Do you still want to continue?Click here for more information
Yes. I am willing to take risk despite the risks stated
No. I want to make consultation with GP
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You are obese(COCP). there are studies stating obese women have higher risk of developing clot, myocardial infarction and stroke with combined contraceptive pill. Highly suggestive for POPClick here for more information
Yes, I will change into POP
No, I wanna continue
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Do you have any sensitivity to medicines or any allergies* This field is required.
Yes
No
16
Please enter things you allergy about
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Is there a history of any illness that runs within your family?* This field is required.
Yes
No
18
Please enter your family illness history
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19
Do you have any medical conditions?* This field is required.
Yes
No
20
Please enter your medical conditions
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21
Have you any history of recurring severe headaches or migraines?* This field is required.
Yes
No
22
If you have migraine, Please read this link and confirm if your migraine is with Aura or without Aura.

Once finished please click NEXT
23
Please confirm your migraine is with Aura or without Aura
Yes, I have migraine with Aura
No, I have migraine But WITHOUT Aura
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Migraine with Aura is Contraindicated to take Combined Contraceptive Pill as it increases risks of Stroke. You can read more here

We would advice you should change your contraception to Single Hormonal pill Progesterone only.

Would you like to continue with Pill Prescription? Please click "NEXT" for selecting
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Would you like to continue with Pill prescription even you have Aura?
Yes, I want to continue.
No, Please lead me to the pill choice question.
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Have you ever had a blood clot?* This field is required.
Yes
No
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You are not suitable for Combined Contraceptive Pill as COCP increases risks of blood clot in the legs and lung. You can read more here

We would advice you should change your contraception to Single Hormone Progesterone only.

Would you like to continue with Pill Prescription? Please click "NEXT" for selecting
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As you are unsuitable for combined pill prescription, if you would like to continue this service, please click next to return to pill choice and choose from option - Single Hormonal progesterone pill only
Click here to return to pill choice question.
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Are you up-to-date with cervical smears?* This field is required.Cervical smears are usually carried out every 3 years. Smears may be needed more frequently if there has been a previous abnormal smear?
Yes
No
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please visit website here to check when you are next due for your smear tests.

You can book appointment under Free Services on our website for free smear tests.

Please click NEXT to continue Contraception Consultation
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Do you smoke or have you recently quit smoking?* This field is required.
Yes
No
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Select your smoking situation
Please Select
Please Select
more than 15 ( >= 15 )
less than 15 ( < 15 )
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(COCP)There are risks associated with both smoking and oral contraceptives separately, due to their effects on blood flow, but together they can be a deadly combination. Studies have shown that blood vessels in smokers often become hard and restricted. It may be suitable for under 35 but unsuitable above over 35. As you are above age 35( > 35)and smokes, Your risks of taking COCP increases health risks and may be unsuitable for COCP. This template is unsuitable for you and you should discuss with GP.
I still like to continue with COCP despite this advice
I like to change contraception for Progesterone only Pill
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There are risks associated with both smoking and oral contraceptives separately, due to their effects on blood flow, but together they can be a deadly combination. Studies have shown that blood vessels in smokers often become hard and restricted. It may be suitable for under 35 but unsuitable above over 35. We would strongly advise to stop smoking to reduce this risks. if you accept this risks, you can continue with this consultation
I undertstand, and I would like to cotinue
I don't want to continue, I would like to see doctor.
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Do you have any problems with your menstrual Period?* This field is required.
Yes
No
36
Do you have any signs or symptoms of Intermenstrual Bleed or Post Coital Bleed and have you consulted your GP about this?If you have any signs or symptoms of Intermenstrual Bleed or Post Coital Bleed and you have not consulted your GP about this, you MUST book appointment with your GP to review this as soon as possible. You can read more about Post Coital Bleed here You can read about Intermenstrual Bleed here
I have intermenstrual bleed or post coital bleed not seen or discussed with Doctor
I DO NOT have intermenstrual bleed or post coital bleed not seen or discussed with Doctor
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Do you have any side-effects from this contraceptive* This field is required.
Yes
No
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Please enter your side-effect
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39
Despite these side effects, do you want to continue with same treatment/pill choice?
Yes
No
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During your last cycle of treatment did you forget any pills or were you more than 12 hours late taking any pills or have any problems using your NuvaRing or Patch in the prescribed manner* This field is required.
Yes
No
41
You may not be suitable for oral contraception or patch/ring. You should consider Long Term Reversible Contraception (LARC) You can read more from here

Please click NEXT to continue Contraception Consultation
42
Despite POOR compliance of using pill/patch/nuvaring, do you want to continue with same treatment/pill choice being aware there is HIGH risks of failure of this choice as a contraception method?
Yes
No
43
Are you pregnant?* This field is required.
Yes
No
44
Are you planning to become pregnant within the next six month?
Yes
No
45
You can book appointment with GP and arrange Health Screening. You can book appointment online .

Please click NEXT to continue Contraception Consultation
46
In your immediate family (mother, father, brothers and sisters) is there any history of Breast/Ovarian/Uterine cancer?* This field is required.
Yes
No
47
As you have family history of breast/ovarian/uterine cancer, your risks with COCP use increased. Do you accept this risks?
Yes
No
48
Other than issues already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?* This field is required.
Yes
No
49
Please provide more information medical relevant for contraception not asked
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When did you last have your blood pressure taken?* This field is required.
< 6 months
>= 6 months
51
Please write down your blood pressure reading* This field is required.
Diastolic (lower number) mmHg
Systolic (higher number) mmHg
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If blood pressure >140/90mmHg, you are unsuitable for COCP, you may need to consider for POP. would you like to continue?
Yes. I would like to change into POP
No. I wanna continue
53
Are you currently or in the last two months have you taken any medicine (prescribed or not), alternative medicines or recreational drugs other than those you have mentioned previously* This field is required.
Yes
No
54
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Upload any relevant imaged and file if you need
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Do you need pharmacy delivery service?
Yes
No
57
Please select the pharmacy that you want for delivery service
Please Select
Please Select
Pure pharmacy Foxrock
Health wave pharmacy dundrum
58
Please select the pharmacy that you want for prescription(If you can't find your pharmacy. Please click "NEXT" to fill your pharmacy)
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Please kindly provide the name of pharmacy if you cannot find the pharmacy(please leave its healthmail if you know it ).
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Irish Government introduced a free contraception scheme, available to women at aged 17- 35 with valid PPSN , If you have PPSN number, please click "Yes" and fill it in next page. Otherwise, click "No"
Yes. I qualify
No. I don't qualify
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Please re-enter your PPSN
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Terms and Conditions* This field is required.Before continuing you must agree to Gpdoc Terms and Conditions
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I confirm that I have read and understood this and my answers are fully correct and true.* This field is required.
I confirm
I do not confirm
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Blood Pressure can be obtained at local gym, personal home monitor or pharmacy.

Blood pressure measurement is essential for the safe prescribing of this medicine and should be ideally done whilst at rest, relaxed, seated, caffeine/alcohol free for an hour(> 1 hour) before and no talking whilst BP is measured

Please refill this questionnaire once you had blood pressure data, otherwise your request won't be processed
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This template is only for female patient.
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Please kindly book Video/Face to Face Appointment to discuss further.

You can book online at here

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Please click SUBMIT to submit your questionnaire

What happens after this?
1.) you will receive confirmation via email when your prescription has been sent electronically by your pharmacy selected by you.

2.) You MUST contact the pharmacy upon receiving the confirmation email of prescription to activate the prescription and pharmacy will prepare the prescription for you. You must indicate to pharmacy about collection or delivery.
Pharmacy will advice charges or prescription or delivery accordingly.

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