Are you registered with a GP practice in the UK?
Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost
confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with
important information which will help them make an informed decision in deciding if the
treatment is considered to be suitable for you).
Do you believe you have the capacity to make decisions about your own healthcare?
Are you female?
Are you breast feeding or pregnant or possibly pregnant?
Do you have an allergy (hypersensitivity) to norethisterone?
Do you or your family members have a history of deep vein thrombosis (DVT)?
Have you been diagnosed with any of the following?
Are you taking any type of hormonal contraceptives (e.g. oral or injections)?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
Do you understand that this medication should be only be used for delaying your period?
Do you agree to the following?