Please fill out the Morning After Pill form below and we will be in touch, Thank You. Your First Name* Your Last Name* Your Address* Date of Birth* This service is open to women 18 years old and over. If you are over 17 years old you will have to call into the pharmacy to obtain a supply of the morning after pill. If you are under 17 years of age you will have to attend your G.P. or an out of hours clinic to obtain the morning after pill. Medical Card* YesNo Please input number if you have a medical card. Time since unprotected sex* under72 hrs72-120 hrsover 120 hrs Is the medication for your own use? YesNo Is there any chance you may already be pregnant before this episode of unprotected sex? (Was your last period late/early, heavier or lighter than usual? did you have unprotected sexual intercourse in your last cycle?) YesNo Have you used any form of emergency contraception since your last period? YesNo If so please list below: Are you breastfeeding? YesNo OTHER MEDICATION Are you taking any other medication? YesNo If so, please list: Do you suffer from any illnesses, conditions or allergies? YesNo If so please list below: Have you taken any other medications in the last twelve weeks? YesNo If so please list Contact Phone Number* Please attend the pharmacy as soon as possible to discuss with our pharmacist the options available to you and appropriate advice on how to proceed. I confirm that the Information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that Hanley's Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.