Dunsville Medical Centre

01302 890108
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Delay a Period

You may wish to delay a period if it is due at a time that would be inconvenient, such as a holiday or exam.   If you are not already taking ‘the pill’ then a hormone tablet could be prescribed for this.

Please complete this form to request a prescription to delay a period.

PLEASE NOTE – THIS FORM MUST BE COMPLETED AT LEAST 2 WEEKS BEFORE YOUR EVENT / HOLIDAY.

 

Request for Prescription to Delay a Period

This form provides the GP with important information, including to assess your risk of thrombosis / DVT. Please FULLY COMPLETE the form.

Please enter Full Name - First name, middle initial if appropriate and surname
Date of Birth(Required)
Your date of Birth
Your Address
Please enter your Mobile or Home Telephone Number
Date of Event / Holiday(Required)
AT LEAST 2 WEEKS NOTICE IS REQUIRED BEFORE TRAVEL / EVENT. Please select the date from which you want to delay your period
Please enter the number of days the Event or Holiday will last
Date of expected period(Required)
Please enter the approximate date your period is expected (in relation to the event / holiday)
Have You personally suffered from a blood clot, or been told you have an increased risk of this condition?(Required)
Is there any Family History of blood clots or deep vein thrombosis (DVT)(Required)
Please confirm if any members of your family have had blood clots or DVT.
Current Smoker(Required)
Please provide average / approximate daily number of cigarettes/ cigars or weight of tobacco.
Please add your name as a digital signature
Date of Signature(Required)
Declaration(Required)