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Contraception Injection Form

Doctor holds solution for injection and syringe in hand

US$ 10,00

Easily & affordably receive 6 month prescriptions for your Injectable birth control/contraception.

Please note that this clinical form is for Injectable contraception requests only. Please click here if you require an Oral or Patch contraceptive.

The cost of medication is not included in this prescription

Name

Surname

Phone Number

Email

ID Number

Have you used our services before?

Address

City

Postal Code

Have you used Injectable birth control before?

When was your last menstrual period?

Do you experience any of these menstrual issues?

Heavy bleeding Severe pain Irregular periods Other None of the above

Are you pregnant or breastfeeding?

What is your current weight in Kilograms (kg)?

What is your current height in Centimeters (cm)?

Have you taken a blood pressure test in the last 12 months?

Was your latest blood pressure reading NORMAL? (lower than or equal to 139/89 mmHg and higher than 90/60 mmHg)

Do you smoke?

Do you have any of these medical conditions?

Stroke Heart Disease Diabetes High Blood Pressure (including pregnancy related hypertension) High Cholesterol Liver Disease Gallbladder Disease Thyroid Disease Breast Cancer Family History of Breast Cancer Endometrial Cancer Cancer Thromboembolic disease Severe Headaches More than once a week Migraines with an aura Organ Transplantation Lupus (SLE) Porphyria None

Do you have any of these conditions related to blood clotting?

Blood clotting disorder Currently using or used blood clotting medication Previous blood clots Prolonged bed rest Unable to move any limb DVT (deep vein thrombosis) None

Do you have any other medical conditions?

Are you using any of these medications?

Oral Antifungal Treatment Ciclosporin Amiodarone Oral blood thinning medication (including Warfarin, Clopidogrel, Rivaroxaban, Heparin) Aminoglutethimide TB Medication Seizure Medication (including Lamotrigine, Carbamazepine, Topiramate, Oxcarbazepine, Phenytoin, Barbiturates, Primidone) St. John’s Wort None

Are you currently taking any other medication?

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service. I understand the questions above and have answered honestly. I understand that any inaccurate or false information could potentially be dangerous to my health and safety. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.I agree to the Terms & Conditions of this platform.I am 18 years or older.I am currently living in Zimbabwe

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

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