Morning After Pill Ordering Form

Your First Name*

This is a required field.

Your Last Name*

This is a required field.

Your address

The reason we ask for your address is that we need it to enter onto our Patient Medical Record (PMR) along with the supply of the morning after pill

Street*

This is a required field.

City*

This is a required field.

Zip*

This is a required field.

County/Region*

This is a required field.

Date of birth*

This service is open to women 18 years old and over. If you are under 18 please call any of our pharmacies to discuss your options (Note: under 18’s can still purchase the morning after pill from McCabes Pharmacy, but must visit their local McCabes Pharmacy first).

This is a required field.

If you have a medical card please enter your number here, alternatively you can bring your medical card with you to the pharmacy.

ADDITIONAL INFORMATION

Time since unprotected sex.

under 72 hrs 72-120 hrs over 120 hrs

Please select one of the options.

Is the medication for your own use?

Yes No

Please select one of the options.

Is there any chance you may already be pregnant before this episode of unprotected sex?

Yes No

Please select one of the options.

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

Yes No

Please select one of the options.

If so please list below:

Are you breastfeeding?

Yes No

Please select one of the options.

OTHER MEDICATION

Are you taking any other medication?

Yes No

Please select one of the options.

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

Yes No

Please select one of the options.

If so please list below:

Contact Phone Number*

This is a required field.

Email Address*

This is a required field.

Please enter a valid email address (Ex: johndoe@domain.com)

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 4:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 7:00 pm

Thursday: 9:00 am - 8:00 pm

Friday: 9:00 am - 8:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 10:00 am - 5:00 pm

Bank Holiday Monday: 10:00 am - 5:00 pm

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 9:00 pm

Friday: 9:00 am - 9:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 7:00 pm

Thursday: 9:00 am - 9:00 pm

Friday: 9:00 am - 9:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 10:00 am - 6:00 pm

Bank Holiday Monday: 10:00 am - 6:00 pm

Opening hours

Monday: 9:00 am - 5:00 pm

Tuesday: 9:00 am - 5:00 pm

Wednesday: 9:00 am - 5:00 pm

Thursday: 9:00 am - 5:00 pm

Friday: 9:00 am - 5:00 pm

Saturday: 9:30 am - 1:30 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 8:00 pm

Friday: 9:00 am - 8:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 11:00 am - 6:00 pm

Bank Holiday Monday: 11:00 am - 06:00 pm

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 4:00 pm

Sunday: 11:00 am - 6:00 pm

Bank Holiday Monday: 10:00 am - 6:00 pm

Opening hours

Monday: 9:00 am - 9:00 pm

Tuesday: 9:00 am - 9:00 pm

Wednesday: 9:00 am - 9:00 pm

Thursday: 9:00 am - 9:00 pm

Friday: 9:00 am - 9:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 10:00 am - 7:00 pm

Bank Holiday Monday: 10:00 am - 7:00 pm

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 7:00 pm

Thursday: 9:00 am - 7:00 pm

Friday: 9:00 am - 7:00 pm

Saturday: 10:00 am - 4:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 9:00 pm

Tuesday: 9:00 am - 9:00 pm

Wednesday: 9:00 am - 9:00 pm

Thursday: 9:00 am - 9:00 pm

Friday: 9:00 am - 9:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: 11:00 am - 2:00 pm

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 11:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:30 am - 1:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:30 am - 6:00 pm

Sunday: 12:00 pm - 6:00 pm

Bank Holiday Monday: 12:00 pm - 6:00 pm

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 10:00 am - 5:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 11:00 am - 5:00 pm

Bank Holiday Monday: 11:00 am - 5:00 pm

Opening hours

Monday: 9:00 am - 4:00 pm

Tuesday: 9:00 am - 4:00 pm

Wednesday: 9:00 am - 4:00 pm

Thursday: 9:00 am - 4:00 pm

Friday: 9:00 am - 4:00 pm

Saturday: 9:00 am - 1:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 8:00 pm

Tuesday: 9:00 am - 8:00 pm

Wednesday: 9:00 am - 8:00 pm

Thursday: 9:00 am - 8:00 pm

Friday: 9:00 am - 8:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 10:00 am - 6:00 pm

Bank Holiday Monday: 10:00 am - 6:00 pm

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 7:00 pm

Thursday: 9:00 am - 9:00 pm

Friday: 9:00 am - 9:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: 11:00 am - 6:00 pm

Bank Holiday Monday: 10:00 am - 6:00 pm

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 11:00 am - 4:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 10:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 11:00 am - 4:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 10:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 9:00 am - 6:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 6:00 pm

Tuesday: 9:00 am - 6:00 pm

Wednesday: 10:00 am - 5:00 pm

Thursday: 9:00 am - 6:00 pm

Friday: 9:00 am - 6:00 pm

Saturday: 9:00 am - 5:00 pm

Sunday: Closed

Bank Holiday Monday: Closed

Opening hours

Monday: 9:00 am - 7:00 pm

Tuesday: 9:00 am - 7:00 pm

Wednesday: 9:00 am - 7:00 pm

Thursday: 9:00 am - 7:00 pm

Friday: 9:00 am - 7:00 pm

Saturday: 9:00 am - 6:00 pm

Sunday: 11:00 am - 2:00 pm

Bank Holiday Monday: Closed

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 McCabes Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

This is a required field.