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To help us understand that this treatment is the right option for you, please answer the following questions.
This refers to your biological gender
Use the calendar to select your date of birth.
Your height is important for the prescribers decision.
Please make sure to add your current weight. This may affect the prescriber's decision.
If you are male, answer No
If yes, please provide details
Deep vein thrombosis (DVT) and Pulmonary embolism
- Angina- Arrhythmia- Cardiovascular disease
If so, please provide more details
E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency
If yes, please provide details e.g. which pill, patch or other method
Papilloedema and Retinal vascular lesions
If yes, please provide details Please provide details in this box here...
Migraines / Epilepsy / Asthma
Systemic lupus erythematosus / Severe obesity (BMI >30 kg/m2) / Thromboembolism / Recurrent miscarriage
- You declare that I have answered the above truthfully- You will read the patient information leaflet before taking your medication (if prescribed)- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment- 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 this questionnaire is part of a request to the doctor and the final decision will rest with the doctor
Unfortunately we cannot offer you any treatments for this condition. Please feel free to contact us for more information.
