Period Delay Treatment

A licensed doctor reviews your answers before issuing this prescription.

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Prescription

Period Delay Treatment

€25 — reviewed by a licensed doctor before your prescription is issued.

Patient details

Patient full nameEmailPhone

Date of birth

Enter a date up to 17/10/2026.

PPS number (optional)

Needed on medical documents in your country. You can also fill it in on your profile later.

Preferred pharmacy (optional)

Type at least 2 characters to search.

My pharmacy is not listed

IE · Period delay · Full

This form is used to assess your suitability for period-delay medication. It is reviewed by an Irish-registered doctor before any prescription is issued — this is not a live consultation, so please answer every question fully and honestly. Both medications used for period delay require the doctor to make the final decision on which is most suitable for you; this may not match your own preference if your answers indicate a different option is safer.

Your request

When is your period due? (expected start date)

How many days would you like to delay it by, and why? (e.g. holiday, exam, wedding)

Do you have a preference between the two available medications, or would you like the doctor to choose the most suitable one for you?

Your health

Is there any chance you could be pregnant, or are you currently trying to conceive?

Are you currently breastfeeding?

Have you ever been diagnosed with a blood clot (DVT or pulmonary embolism) or a clotting disorder?

Has a first-degree relative (parent or sibling) had a blood clot?

Have you ever had a stroke, heart attack, or angina?

Height (cm)

Weight (kg)

Do you have liver disease, a liver tumour, or a history of jaundice during a previous pregnancy?

Do you have, or have you ever had, breast cancer or any other hormone-sensitive cancer?

Do you have any abnormal or unexplained vaginal bleeding that hasn't yet been investigated by a doctor?

Do you have high blood pressure?

Do you get migraines?

Do you have any of the following conditions? (select all that apply)

Lupus (SLE)EpilepsyDiabetesNone of the above

Do you currently smoke?

Have you had any major surgery, or a period of significantly reduced mobility (bed rest, a long-haul flight, or an immobilised limb) in the last 4 weeks?

Are you currently taking any other medications, including blood thinners?We fill this in from your medical profile when we have it. Write "None" if you take none.

Is there anything else you think the doctor should know before making a decision?

Patient address

Required for medical documents and any physical materials.

Street addressApt / unit (optional)CityEircode (optional)

Data sharing consent (GDPR)

I confirm the details above are accurate and consent to a video consultation with the selected clinician.I consent to my personal and medical data being processed by Global Health and shared with its treating clinics and medical network — including clinics in other countries — for the purpose of my care, service improvement, and security. Privacy PolicySend me appointment updates via WhatsApp (optional)