Period Delayed Request Form

Delayed Periods

Request for Medication to Delay Menstruation

Please note that these requests can take up to a week to complete and that the pharmacy will then need 48 hours to process the prescription.

If you require your medication before this we recommend that you consider looking at undertaking an online assessment with a private provider whop can provide the same medication for a charge.

Please use one form per patient.

Patient Information

First Name *

Last Name *

Email *

Date of birth *

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

Phone Number *

Do you consent to us contacting you via (please tick which you consent to):

Text

Which GP Practice or Pharmacy would you like your prescription to be sent to?

Form completed by:

I am the Patient

Yes

I have permission from the patient to complete this on their behalf.

Yes

I am the Patient’s: I am the Patient's:

Information about your period

Why do you need to delay your period?

What is the earliest date that your period will arrive? *

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

Are your periods regular?

Yes

How long do your periods last?

How long do you need to delay your periods for?

For instance, what is the date that you want your period to start?

When was your last period? *

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

If you are human, leave this field blank.

Patient Information

Information about your period

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