Emergency Contraception
Slattery's Pharmacy

First Name *

Last Name *

Date of Birth *

Email Address *

Phone *

Address *

Eircode

County of Residence * Please, select Carlow Cavan Clare Cork Donegal Dublin Galway Kerry Kildare Kilkenny Laois Leitrim Limerick Longford Louth Mayo Meath Monaghan Offaly Roscommon Sligo Tipperary Waterford Westmeath Wexford Wicklow

Your GP's name and contact details *

Time since unprotected sex * 0-72 Hours 72-120 Hours Over 120 Hours

Days into cycle (The first day of your period is day one). Leave blank if unknown.

Is the medication for your own use? Customers must attend in person to collect the morning after pill. *

Prior Sex or Pregnancy? Is there any chance you may already be pregnant before this episode of unprotected sex? *

Used before this cycle? Will this be the first time you have used Emergency Contraception since your last period? 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 Currently Breastfeeding? So our pharmacist knows to offer the best product. *

Are You Taking Other Medications? Some customers are on medication that could make the morning after pill less effective. The following questions help the pharmacist establish the best emergency contraception option for you. *

Please List Medications

Do you suffer from any illnesses, conditions or allergies? *

Please List Allergies

Continue to Payment Amount due: €30