Delayed Menstruation Request Form

Delayed Periods

Request for Medication to Delay Menstruation

Please note that these requests can take up to a week to complete and that the pharmacy will then need 48 hours to process the prescription.

If you require your medication before this we recommend that you consider looking at undertaking an online assessment with a private provider whop can provide the same medication for a charge.

Please use one form per patient.

Patient Information

Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
Do you consent to us contacting you via (please tick which you consent to):
I am the Patient
I have permission from the patient to complete this on their behalf.
As you have confirmed that you do not have the patient’s permission to complete this form on their behalf you will not be able to submit this.

Information about your period

Please use format day/month/year e.g. 12/05/1979
Are your periods regular?
For instance, what is the date that you want your period to start?
Please use format day/month/year e.g. 12/05/1979