Emergency Contraception

Emergency contraception, commonly known as the morning after pill, is available in Drimoleague Pharmacy, West Cork, without a prescription, subject to meeting certain criteria.

You can fill out this form from the comfort of your home, and we will prepare your medication for you based on the answers you have provided. We will contact you when it’s ready.

Please note the “click & collect” online order service is subject to availability and must be within the pharmacy opening hours. Please check the pharmacy opening hours before proceeding.

Emergency contraception is a safe and effective method of preventing pregnancy when regular contraception has failed or if no contraception was used.

It can be effective up to 120 hours after unprotected sex but is more effective the sooner you use it.

This service is available free of charge for medical card holders and to women aged 17-26 under the National Free Contraception Services Scheme. A fee applies to anyone who does not have a medical card. To find out more, speak to your local pharmacist.

By completing the online consultation form in advance, the pharmacist can have your completed form and medication ready and waiting for you when you arrive at the pharmacy.

Full Name

Date of Birth

This service is open to women over the age of 17 years old. If you are under 17, please call the pharmacy to discuss your options.

Address

Contact Number

By entering your phone number here, you are consenting to the pharmacist contacting you by phone if the pharmacist needs to discuss your questionnaire or to carry out a phone consultation. If you do not consent to being contacted and want to complete the consultation in the pharmacy, please visit the pharmacy in person during opening hours: Monday - Saturday 9am - 6pm

If you have a medical card, please enter your GMS number (alternatively you can bring your medical card with you to the pharmacy)

GMS

Yes No

GMS number (if applicable)

Are you currently aged between 17-26 years?

Yes No

PPS Number (if you answered yes above)

Time since unprotected sex

This helps us to choose the correct product. One of the products can be taken up to 5 days (120 hours) after unprotected sex, but with all emergency contraceptives the sooner emergency contraception is taken the more effective it is. If it has been over 120 hours, please contact your GP.

Is this medicine for your own use?

Yes No

Customers must attend in person to collect the Emergency Contraception.

When was the first day of your last period?

This helps the pharmacist establish the risk of pregnancy. Leave blank if unknown.

Was your last period normal?

Yes No

Is there a chance you may already be pregnant before this episode of unprotected sex?

Yes No

Will this be the first time you have used Emergency Contraception since your last period?

Yes No

Emergency Contraception can be taken more than once in a cycle, but the pharmacist needs to know this so they can select the most appropriate product.

Are you breastfeeding?

Yes No

Medical History & Current Medications

Some people are on medication that could make Emergency Contraception less effective. The following questions help the pharmacist establish the best Emergency Contraception option for you:

Are you taking any medication, including any contraceptive methods?

Yes No

If you answered yes above, please specify:

Do you suffer from any illnesses, conditions, or allergies? (Such as Epilepsy, liver or bowel disease or chronic Asthma?)

Yes No

If you answered yes above, please specify:

Do you have a history of ectopic pregnancy or Salpingitis (inflammation of fallopian tubes)?

Yes No

Have you ever experienced a thromboembolic event? (i.e Deep vein thrombosis/ Heart attack/stroke, Angina, Pulmonary embolism, Transient ischemic attack)

Yes No

Are you currently experiencing vomiting or diarrhoea?

Yes No

What happens next?

Once you click confirm, Drimoleague Pharmacy will receive your order details. The pharmacist will review the information and, if approved, prepare your order. You will be notified once your medication is ready for collection at your chosen pharmacy (during store opening hours). You will still need to go to the pharmacy yourself to collect the medication.

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 my pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

Emergency Contraception

Medical History & Current Medications

What happens next?

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