Period Delay Form – Clockwork Pharmacy

Period Delay - Norethisterone - Risk Assessment Form

PATIENT PERSONAL DETAILS

Title: Mr. Miss. Ms. Mrs. Dr.
Name:	Surname:
Email:	Mobile:
Patient address:	GP Name and address: (optional)
Gender: Male Female	Date of Birth:

Treatment Information

Norethisterone 5mg tablets are used to postpone menstruation for adult females (18-50 years old).
This treatment is intended for occasional use only (maximum one supply every six months).
If more frequent treatment is needed, consultation with a GP is required.
This medication is not a contraceptive and will not prevent pregnancy.

Medical History & Assessment

Height (m):

Weight (kg):

Question	Response
Are you between 18 and 50 years old?	Yes No
Do you understand that this medication is for period delay only and not regular use?	Yes No
Do you wish for your GP to be informed of this supply?	Yes No

Do you have any of the following conditions? (Tick all that apply)

Condition	Response
Allergy to norethisterone or its ingredients	Yes No
Pregnancy, breastfeeding, or trying to conceive	Yes No
Severe liver disease	Yes No
Kidney disease requiring dialysis	Yes No
Unexplained vaginal bleeding	Yes No
History of blood clots (DVT, PE)	Yes No
History of heart disease, angina, or stroke	Yes No
Migraine with aura	Yes No
Diabetes	Yes No
Epilepsy	Yes No
Asthma	Yes No
Porphyria	Yes No

If you ticked any of the above, discuss with the pharmacist before proceeding.

OUR SERVICE IS A PRIVATE SERVICE AND NOT COVERED BY THE NHS

Our pharmacy offers professional, compassionate care—providing expert advice, timely service, and ongoing support to ensure every patient’s well-being and satisfaction.

Walk in anytime—Walk in for weight loss meds—no wait, no appointment!

Period Delay - Norethisterone - Risk Assessment Form

Do you have any of the following conditions? (Tick all that apply)

215-217 Hackney Greater London E9 7HD