To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Born male
Born female





Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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Please select either Metric or Imperial measurements :

Metric (Centimetre and Kilograms)
Imperial (Feet and Pounds)



This may be to any medicines or other substances e.g. peanuts/soya)


Either prescribed or over the counter, including herbal remedies, supplements, or recreational drugs.




If yes, please state what your reaction was.


If yes, please state when.







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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • You are aware of the side effects of ellaOne/levonelle (or the generic alternative), which can be found in Section 4 of the patient information leaflet
  • You confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.



Please state your registered GP if you haven't done so already when signing up