Progress

General Consultation

What type of contraception service are you seeking today?

I want to start a contraceptive method

I want to continue with my current contraceptive method

Have you used contraception before?

No, this is my first time using contraception

Yes, but I stopped using it and now want to restart

Yes, I'm currently using a method but want to change to a different one

Have you had a blood pressure check within the last 4 weeks?

Yes

What is your height (so that we can calculate your BMI)?

Value must be between 100cm and 220cm

Switch to ft, in

What is your weight (so that we can calculate your BMI)?

Value must be between 40kg and 250kg

Switch to st, lb

Do you currently smoke or have you smoked in the past?

This also includes vaping and e-cigarettes.

I have never smoked

I used to smoke but quit more than 12 months ago

I used to smoke but quit within the last 12 months

I currently smoke

Have you ever experienced migraine with aura (visual disturbances such as flashing lights, zigzag lines, blind spots, or numbness/tingling in face or hands before headache begins)?

Yes

Do any of the following apply to you?

I have a condition that significantly limits my mobility (e.g., use of wheelchair, leg cast)

I have recently had or am planning surgery requiring bed rest

I am on bed rest due to illness or medical advice

I am planning a long-distance travel (over 4 hours) in the next 4 weeks

None of the above

What are your reasons for requesting a contraceptive?

This will allow our clinicians to provide you with the most appropriate treatment tailored to your needs.

Certain conditions may reduce pill effectiveness, in these cases, Long-Acting Reversible Contraception (LARC) methods may provide more reliable protection.

For example:

Digestive disorders affecting absorption
Medications causing diarrhea/vomiting
Taking medication that requires pregnancy prevention

I understand and will discuss with pharmacist if applicable to me

Are you allergic to any medication?

Some combined oral contraception contain lactose/ sucrose. Individuals with rare hereditary problems of galactose intolerance, total lactase deficiency, fructose intolerance or glucose-galactose malabsorption or sucrase-isomaltase deficiency should not take these medicines.

Yes

Are you currently taking any medication?

Yes

Have you been diagnosed with any medical or mental health conditions?

Yes

Are you currently pregnant or breastfeeding?

Is there any other information you would like to share with our clinical team?

Family history of any cancer diagnosis or blood clots
Previous history of cancer diagnosis or blood clots

Yes

Do you agree with the following:

We may need to verify some of your health information using your NHS GP health records. This includes checking for previous medical and medication history to reduce risk of any interactions with your hormonal contraception.
You agree that one of our pharmacists may contact you by phone to discuss suitability of treatment using the phone number you provide.

I Agree

Important information to know about contraceptive treatment.

You understand that the contraceptive tablet must be taken at the same time every day in order for it to be effective. If you are provided the progesterone only pill (mini pill) you must take this medicine within a 3 hours time frame
You understand that contraceptive tablets do not protect against sexually transmitted disease and it is recommended to use a barrier method such as condom to reduce risk of transmission.
You understand that if you are starting this treatment for the first time or after a pause you should also use an extra method (such as condoms) for the next 7 days. You will be advised appropriately by our pharmacist.
You understand that if you miss a pill, or take it late, the pill may not be as effective and you may become pregnant. If you miss a pill you can find out what to do by reading the patient information leaflet, speaking to a medical professional, or using the free Ask A Pharmacist service.
You understand that if you have diarrhoea or vomiting, your pill may be less effective. If this happens, you can find out what to do by reading the patient information leaflet, speaking to a medical professional, or using our free Ask A Pharmacist service.
You understand that this medication can increase your risk of suffering from a blood clot. You will immediately contact a medical professional if you experience unexplained shortness of breath, chest pain, suddenly collapse, or if you notice pain, swelling, and tenderness in one leg (usually the calf).
You understand that some contraception medication can increase the risk of breast cancer. You know how to examine your breasts for breast lumps and will contact your GP if you have or have ever had breast cancer in the past it may be unsafe to take certain contraceptive medications. You must include this information in this consultation as well as if you have an undiagnosed breast lump.
You understand that current use of combined hormonal contraception is associated with a small increased risk of breast cancer which reduces with time after stopping combined contraception.
You understand that current use of combined hormonal contraception for more than 5 years is associated with a small increased risk of cervical risk which reduces over time after stopping COC and is no longer increased by about 10 years after stopping.
You understand that current use of combined contraception is associated with an increased risk of blood clots (DVT), if you plan to travel ensure you are reducing periods of immobility.
You understand that if you are trekking to high altitudes (above 4500m or 14500 feet) for periods of more than 1 week you may be advised to consider switching to a safer alternative contraceptive method.
You understand you may be advised to stop combined contraception and to switch to an alternative contraceptive method at least 4 weeks prior to planned major surgery or an expected period of limited mobility.
You understand and confirm that requesting treatment through this service does not guarantee a supply. If treatment is not suitable, you will be signposted to another point of care. The decision about the treatment is for both the patient and the pharmacist to consider, however, the final decision will always lie with the pharmacist.

I understand

You agree to the following:

This treatment is for your use only
You have the capacity to make decisions about your own healthcare
You have understood all the questions and have answered this consultation truthfully and completely
You will read the patient information leaflet supplied with this medication
You understand that our system will first need to validate your age before processing your order.
You understand the clinical team will take your answers in good faith and base their clinical decisions accordingly, and that incorrect information can be hazardous to your health
You accept that once medication has been dispatched we can not cancel your medication request. You understand that this service is commissioned by NHS England and final decision of suitability of treatment is based on pharmacist’s review of information provided.
You will contact Evaro and inform your GP if you experience any side effects from this treatment or if there are any changes to your health
You have read, understood, and agree to abide by our terms and conditions of website use, terms and conditions of sale, privacy policy, delivery, refund policy, and cookie policy.

I Agree

Full Name *

Date of Birth *

Gender at Birth*