Emergency Contraception

If you have had unprotected sex within the last 5 days, we offer the emergency contraceptive pill to help prevent pregnancy when other forms of contraception have failed. Please fill out the form below so that our pharmacists can determine if the treatment will be suitable for you to take. Our pharmacist will contact you shortly after this questionnaire via video-call to confirm details to determine if this is the right product for you.

PLEASE NOTEDue to the nature of this medication, this can only be issued to patients in Dorking or surrounding areas.

Pharmacy Mentor



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 (Meters and Kilograms)
Imperial (Feet and Pounds)














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