Contraception (Pill, Patch or Ring)

A licensed doctor reviews your answers before issuing this prescription.

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01Details

Prescription

Contraception (Pill, Patch or Ring)

€15 — reviewed by a licensed doctor before your prescription is issued.

Patient details

Patient full nameEmailPhone

Date of birth

Enter a date up to 18/10/2026.

DNI / NIE (optional)

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

ES · Anticonceptivo · Completo

Este formulario lo revisa un médico colegiado antes de emitir cualquier receta. Por favor, responda a todas las preguntas con detalle y con sinceridad.

¿Qué método solicita?

¿Fuma?

¿Tiene migrañas?

Antecedentes personales o familiares de trombosis (TVP/EP), ictus o infarto

Altura y peso

Altura (cm)

Peso (kg)

Su salud

Tensión arterial

Cáncer de mama o sangrado vaginal sin causa conocida

Posparto o lactancia

¿Podría estar embarazada ahora mismo?

Diabetes

¿Toma hierba de San Juan, o medicamentos para la epilepsia, para el VIH o del tipo de la rifampicina?

Patient address

Required for medical documents and any physical materials.

Street addressApt / unit (optional)CityPostal code

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)