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Menstruation Delay Request

Request for Medication to Delay Menstruation

Thank you for your request to discuss options to postpone your period. This medication can be bought over the counter via online pharmacies. As your GP, we can prescribe medication if there are no contraindications but this can take longer to obtain. If you wish for the GP to prescribe please fill out the form below. Please note this can take up to 7 days to be processed.

Before completing this form, please ensure you are able to provide a blood pressure reading. You can check your blood pressure for free at most pharmacies or purchase a blood pressure monitor.

Please also note if you are needing to delay your period for more than 2 weeks you will need to arrange a routine telephone appointment with a clinician instead of completing this form. Please fill out the practice triage form instead: https://accurx.nhs.uk/patient-initiated/M85086.

Menstruation Delay Request

Your Details

Enter Email
Please use format day/month/year e.g. 12/05/1979

Reason for Request

Medical History

Do you have any history of the following (please tick all that apply):

Family History

Do you have any FAMILY history of the following (please tick all that apply):

Contraception & Maternal History

Are you currently using any hormonal contraception? Please select:
Are you currently pregnant or could be pregnant?
Are you currently breastfeeding?
Have you given birth within the last 6 weeks?

Health Monitoring

Smoking Status
e.g. 120 / 70

Confirmation

  • I understand this is not a contraceptive, alternative contraception is still needed
  • The tablets must be taken consistently and not missed
  • Periods may return heavier or irregular after the course
  • Mild side effects may include breast tenderness, bloating or mood changes
  • I will stop treatment and see advice if leg/chest pain, breathlessness or vision changes
  • I will read the enclosed patient information leaflet and speak to pharmacist if I have any further concerns
  • I understand that this is a short term treatment and not for long term use
  • I will follow the dosing instructions and use additional contraception if needed.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.