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Emergency Contraception

Morning After Pill Consultation Form

Emergency Contraception is a safe, responsible, and effective method of preventing pregnancy when regular contraception has failed or if no contraception was used. Emergency contraception is available at Farrell’s Pharmacies without a doctor’s prescription, subject to meeting certain criteria.

If you think you may need emergency contraception, it is advised to attend your pharmacy promptly (during opening hours) as emergency contraception can be more effective the sooner you take it. Emergency contraception does not protect against sexually transmitted infections. To find out more information on Emergency Contraception and STIs, talk to your Pharmacist or visit www.thinkcontraception.ie.

To save you time, we have an online consent form that can be completed in advance. Your pharmacist will then overview your completed documents and complete a quick review with you, during which you will be given information on how to take the medication, potential side effects and be given an opportunity to ask questions. The medication is provided once it has been deemed safe and suitable for use by you.

An entry will be made on the Patient’s Medication Record (PMR) on the pharmacy computer, in line with good pharmacy practice. Patients can be assured of the confidentiality of such records. The management of any data or information recorded, collected, or retained will be in accordance with relevant legislative provisions.

The current cost of this service, including the medicine is €25. You will not be charged any fee if the pharmacist finds that it is unsafe to supply you with the medicine. Available free for medical card holders.

BASIC INFORMATION

Choose a Branch*

First Name*

Surname*

Address*

Date of Birth*
(This service is available to patients 17 years old and over. If you are under 17 please call our pharmacy to discuss your options).

If you have a medical card please enter your number here, alternatively you can bring your medical card with you to the pharmacy.
Medical Card No

Time since unprotected sex (This helps us to choose the best medication for you) *
Under 72 hrs72-120 hrsOver 120 hrs

Is the medication for your own use? *
YesNo

Is there any chance you may already be pregnant? (an episode of failed contraception or unprotected sex since your last period)
YesNo

Have you used any form of emergency contraception since your last period? *
YesNo

If so, please list below:

Are you breastfeeding?
YesNo

OTHER MEDICATION

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:

Are you taking any other medication, including regular contraception?
YesNo

If so, please list below:

Do you suffer from any illnesses, health conditions or allergies (if so please list below)?
YesNo

If so, please list below:

Acceptance
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 Farrell’s Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out the consultation over the phone. You will still need to come to the pharmacy yourself to collect the medication.

Phone Number

By entering your phone number here you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)

Additional questions, information

WHAT HAPPENS NEXT?

Once you click submit, your pharmacy will receive your details. The pharmacist will review the information and prepare for your consultation.

Trim Branch
Finnegans Way, Trim,
Co. Meath
C15PT02

(046) 9484285
[email protected]

Longwood Branch
Longwood,
Co. Meath,
A83 Y470

(046) 956 0864
[email protected]

Ballivor Branch
Ballivor,
Co. Meath
C15A328

(046) 956 7940 | (046) 9567451
[email protected]

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