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Medical Assessment for Period Delay

Complete this short online consultation so our medical team can show you suitable treatments.

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Tell us about yourself
Are you female and aged between 18-55?
About Your Symptoms
Are you breast feeding or pregnant or possibly pregnant?
Do you have an allergy (hypersensitivity) to norethisterone?
Do you or your family members have a history of deep vein thrombosis (DVT)?
Have you been diagnosed with any of the following?
  • irregular vaginal bleeding of unknown cause
  • diabetes
  • depression
  • epilepsy, migraine, asthma, kidney or heart problems
  • myocardial infarction (heart attack)
  • High blood pressure
  • Angina
  • Any liver disease or disturbance of liver function
  • jaundice or herpes during pregnancy
  • severe itching
  • Dubin-Johnson Syndrome (chronic jaundice (yellowing of the skin or eyes)) or Rotor Syndrome (jaundice in childhood)
  • an inherited disorder of the red blood pigment haemoglobin (porphyria)
  • cancer of the breast or genital tract
  • any serious medical condition which may require immediate hospitalisation
Your Health Information
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any type of hormonal contraceptives (e.g. oral or injections)?
Patient Declaration & Agreements
Do you agree to the following?
  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully
  • 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 whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber.
Do you understand that this medication should be only be used for delaying your period?