Injectable Contraception

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Patient Info
Payment

Date

Time

First Name

Last Name

Contact Number

ID Number

Date Of Birth

Have you used our services before?

Yes

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Have you used Injectable birth control before?

Yes

What Injectable birth control are you currently using and for how long have you been using it?

When was your last menstrual period?

Do you experience any of these menstrual issues?

Heavy bleeding

Severe pain

Irregular periods

Other

None of the above

Please make sure to have a pap smear and further investigations to determine the cause of the heavy bleeding.

Please make sure to have a pap smear and further investigations to determine the cause of the severe pain.

Other menstrual issues

Are you pregnant or breastfeeding?

Pregnant

Breastfeeding

⛔ Please Do not proceed, this condition will disqualify you from receiving a prescription.
Please click here to WhatsApp our On Call Doctors for an instant consultation. The doctor will advise on a treatment route that will suit you personally.

What is your current weight in Kilograms (kg)?

What is your current height in Centimeters (cm)?

Your BMI is:

⛔ Please Do not proceed, BMI greater than 35 will disqualify you from receiving a prescription.
Please click here to WhatsApp our On Call Doctors for an instant consultation. The doctor will advise on a treatment route that will suit you personally.

Have you taken a blood pressure test in the last 12 months?

Yes

⛔ Please do not proceed. Measure your blood pressure at your local healthcare facility and return to this medical form if your blood pressure is normal.

Was your latest blood pressure reading NORMAL? (lower than or equal to 139/89 mmHg and higher than 90/60 mmHg)

Yes

Do you smoke?

Yes

How many cigarettes do you smoke per day?

Do you have any of these medical conditions?

Stroke

Heart Disease

Diabetes

High Blood Pressure (including pregnancy related hypertension)

High Cholesterol

Liver Disease

Gallbladder Disease

Thyroid Disease

Breast Cancer

Family History of Breast Cancer

Endometrial Cancer

Cancer

Thromboembolic disease

Severe Headaches More than once a week

Migraines with an aura

Organ Transplantation

Lupus (SLE)

Porphyria

None

Do you have any of these conditions related to blood clotting?

Blood clotting disorder

Currently using or used blood clotting medication

Previous blood clots

Prolonged bed rest

Unable to move any limb

DVT (deep vein thrombosis)

None

Do you have any other medical conditions?

Yes

What medical conditions do you have?

Are you using any of these medications?

Oral Antifungal Treatment

Ciclosporin

Amiodarone

Oral blood thinning medication (including Warfarin, Clopidogrel, Rivaroxaban, Heparin)

Aminoglutethimide

TB Medication

Seizure Medication (including Lamotrigine, Carbamazepine, Topiramate, Oxcarbazepine, Phenytoin, Barbiturates, Primidone)

St. John’s Wort

None

Are you currently taking any other medication?

Yes

What medication are you taking?

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service.

I understand the questions above and have answered honestly.
I understand that any inaccurate or false information could potentially be dangerous to my health and safety.
The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.
I will only receive a prescription for Nur-isterate through this service.
I agree to the Terms & Conditions of this platform.
I am 18 years or older.
I am currently living in South Africa.

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

Prescription

Price: R250.00

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Medical Scheme (Medical aid name)

Membership Number

Dependent Code

ICD 10 Code (DO NOT EDIT)

Submitting this clinical form with any “⛔ (do not proceed)” conditions will disqualify you from receiving a prescription.

Please urgently visit your nearest emergency dept or in-person doctor if you are experiencing symptoms such as severe pain, chest pain, difficulty breathing, allergic reactions, dizziness, weakness, or other severe symptoms. Telemedicine services are not suitable for emergency medical conditions.

Contraception Injection

Injectable birth control is a hormonal contraceptive administered via an injection, typically every 1-3 months. It releases hormones (like progestin) that prevent ovulation and thicken cervical mucus to block sperm. It’s a long-acting, reversible form of contraception.

Contraception Injection

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