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Private treatment request

Period Delay Treatment

This service requires a suitability assessment by one of our pharmacists. Please answer the questions below carefully. If the treatment is not suitable, we will signpost you back to your GP or usual healthcare professional rather than taking payment.

1. Personal information

Please enter the details of the person requesting period delay treatment.

Patients must be aged 16 or over for this service.

2. Medical screening

These questions help us decide whether period delay treatment can be requested safely online. If an answer means the service is not suitable, the form will stop here and explain why.

Pregnancy, breastfeeding and bleeding pattern

These questions check whether period delay treatment is appropriate before a pharmacist reviews the request.

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? *
Are you breast-feeding? *
Do you ever have unexpected or unusual vaginal bleeding, such as bleeding between periods, after sex, or periods that have become much heavier, more painful or different from normal? *
Have you previously suffered from jaundice, chloasma or pre-eclamptic toxaemia during pregnancy? *
Have you previously had severe pruritus or pemphigoid gestationis during pregnancy? *

Blood clot and cardiovascular risk

Hormone treatment can slightly increase the risk of a blood clot. These answers are used to decide whether this online service is suitable.

Have you or a close family member ever had a blood clot, DVT, pulmonary embolism, thromboembolism, or repeated miscarriage? *
Have you ever had a TIA, mini stroke, stroke, heart attack, or been told you have significant heart disease? *
Do you have high blood pressure, or has your blood pressure not been checked in the last 12 months? *
Have you recently had major surgery, major trauma, prolonged bed rest, or are you due to receive surgery? *
Will you be immobile for a prolonged period, for example long-haul travel or bed rest, while using this treatment? *
Do you have inflammation of your veins, superficial phlebitis, or significant varicose veins? *

Medical conditions

Some medical conditions mean the request should be reviewed by your GP or usual healthcare professional instead.

Do you have any liver, heart, or kidney problems? *
Do you have diabetes? *
Do you have endometrial hyperplasia, which is thickening of the uterus lining? *
Do you currently have porphyria or jaundice? *
Do you suffer from severe pruritus, meaning itchy skin all over the body? *
Do you have any eye problems, including papilloedema or retinal vascular lesions? *
Do you suffer from migraines, epilepsy or asthma? *
Do you or your close family have systemic lupus erythematosus, thromboembolism or recurrent miscarriage? *
Do you have a known or suspected cancer, or have you had cancer in the past, such as breast cancer? *

Medicines, allergies and contraception

These answers help decide whether norethisterone is appropriate or whether another approach may be safer.

Are you allergic to norethisterone or any other similar hormone medicines? *
Have you been told by your doctor that you have an intolerance to any sugars, including lactose? *
Are you being treated with steroid hormones? *
Are you currently using a contraceptive pill, patch, ring, injection, implant or intrauterine device? *
Are you allergic to any medicines or other substances? *
Do you have high cholesterol, or do you smoke? *
Important notice
You may not need period delay medication if you already use certain hormonal contraceptives. If you use a combined pill, patch or ring, a pharmacist may advise you how to alter your usual hormone-free break instead.

3. BMI and additional information

This medication may not be suitable for patients with a BMI of 30 or above.

Your calculated BMI
Enter your height and weight to calculate BMI.
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4. Treatment option and payment

Passing this online eligibility screen allows you to continue to payment, but it does not guarantee treatment. A pharmacist will review your answers before supply.

Eligibility check incomplete.
Please complete the gated sections above to check whether you can continue to payment.
Please select the number of days treatment you require *
Total to pay
Payment is only taken if your online answers pass the initial eligibility screen. Final suitability is still assessed by a pharmacist.
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