Period Delay Consultation Form

Period Delay Consultation Form

Period Delay Consultation Form

This service requires an in-person collection at Whittington Pharmacy, 13b Main Street, Lichfield, WS14 9JU before any treatment can be supplied.
Please complete this short form to help our pharmacist assess your suitablility.

You will need to visit the pharmacy for a blood pressure and BMI check before medication can be dispensed. No treatment is charged online.

Your Details

Please provide some information about yourself.
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Post Code

Menstrual Cycle Information

Please provide some details about your menstrual cycle.
First day of your last period

DayMonthYear
Date
Expected date of your next period

DayMonthYear
Date
What date do you want to delay your period until?

DayMonthYear
Date
Reason for requesting period delay

Treatment Information
We offer a short course of Norethisterone 5mg tablets to delay your period. You must start taking the tablets 3 days before your period is due. You’ll need to take one tablet three times a day for up to 17 days maximum.

This medicine is not a contraceptive and should not be used as such.

Treatment is subject to a pharmacist consultation and may not be suitable for everyone.

Treatment Choice

Please indicate which treatment option you would like to request. Final request will depend on your assessment.
Pick choose treatment
Pick a Date and Time for your Appointment
Consent & Submit

Please confirm the following information
Should be Empty: