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Sex*: (Please note this service is for females only)
Female

How many cigarettes do you smoke per day?
Select 0 (I Dont Smoke) 1-15 15+ 30+ Are You Pregnant Or BreastFeeding?
Select No I am Currently Pregnant I am Currently BreastFeeding What was your Blood Pressure in the last 6 months ?
Select I Dont Know Less than 120/80 121/80 to 128/80 (Normal) 130/81 to 139/89 (Normal) 140/90

Do you have any of the following Illnesses?
Select None Stroke or heart attack Liver disease Gallbladder disease High blood pressure (incl. during pregnancy) Severe Headaches more than once a week Cancer Family History Of Breast Cancer Diabetes Bariatric surgery Inflammatory bowel disease (Crohn’s or ulcerative colitis) Breast cancer Organ transplantation Lupus (SLE) Thyroids Migraine with an aura Have you had any of the following related to blood clots?
Select None Previous blood clots Blood clotting disorder Prolonged bed rest Unable to move a limb Any blood clotting medication Do you take any of these medications?
Select None St. John’s Wort TB treatment Phenytoin Oxcarbazepine Carbamazepine Barbiturates Primidone Topiramate Seizure medication HIV treatment Oral fungal treatment Lamotrigine

Do you have any other medical conditions* ?
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Do you have any medical history we need to be aware of* ?
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Do you have any allergies ? *
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Have you used birth control medication before ?
Yes         No

Do you know which contraceptive you want ?
Yes         No (Please prescribe for me)

Please specify the injectables name: Select None Nur-Isterate Depo-Provera

Please specify the patch name: Select None evra

Please specify the contraceptive name: Select Prescribe for me Other Minerva-35 Hy-An Mercilon Diane-35 Yaz-plus Natazia Microgynon-30 Biphasil Qlaira Minerva Nordette Ginette-35 Oralcon Zoely Microval Yaz Yasmin Yasmin-plus Diva-35 Triphasil Femodene Ruby

Please enter the name of the contraceptive *

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I answered the questions truthfully and i understand that any false or inaccurate information could potentially be dangerous to my health and well being

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