Contraception Injection

1. I understand the questions above and have answered honestly. 
2. I understand that any inaccurate or false information could potentially be dangerous to my health and safety.
3. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.
4. I will only receive a prescription for Nur-isterate through this service.
5. I agree to the Terms & Conditions of this platform.
6. I am 18 years or older.
7. I am currently living in South Africa.
   
8. Please note that ID verification is required for all patients
   
9. I confirm that the contact information I have provided is correct and belongs to me. I understand that the platform relies on this information to communicate private healthcare information with me.
10. I will have an in-person medical consultation at least once a year for comprehensive care and physical examination.
11. I acknowledge that a doctor will communicate with me via WhatsApp within 24 hours.

Please remember the following when using contraceptive medications:

• 😷Common side effects include nausea, mood changes, weight fluctuation, and changes in menstruation. Most are mild and should subside over time. However, please urgently visit your nearest emergency department if you experience severe symptoms like intense headaches, chest pain, leg swelling or prolonged bleeding as they can indicate rare but serious conditions.

• 🍌It's important to note that while effective for pregnancy prevention, hormonal contraceptives do not protect against sexually transmitted infections (STIs). Please use barrier methods such as condoms for STI protection.

• 🚭Please do regular breast examinations, regularly monitor your blood pressure and avoid smoking. Smoking while on hormonal contraception can further increase your risk of blood clots. Please also remember to have regular pap smears for safety.

Consent:

• Purpose of Treatment: Nur-Isterate, an injectable contraceptive is given every 8 weeks (2 months) as an intramuscular injection. Its purpose is to prevent pregnancy.

• How It Works: Nur-Isterate prevents ovulation and thickens cervical mucus to reduce the chance of pregnancy. It is a temporary form of contraception - fertility usually returns after stopping, though sometimes there may be a delay.

• Expected Outcomes: Highly effective contraception if injections are given on time. Does not protect against sexually transmitted infections (STIs) - condoms are recommended if STI protection is needed.

• Possible Side Effects:

• Common:

• Irregular bleeding or spotting (especially in the first months)

• • Lighter or heavier periods; sometimes no periods at all
  • Weight gain, breast tenderness, headaches, or mood changes
• Less Common:
  • Acne, bloating, nausea
  • Decreased libido
  • Hair changes (loss or increased growth)
• Rare but Important:
  • Allergic reaction (swelling, rash, difficulty breathing)
  • Blood clots (deep vein thrombosis, pulmonary embolism) – report calf pain, chest pain, or shortness of breath immediately
  • Severe headaches, vision changes, or jaundice (yellowing of eyes/skin)

• Precautions:

• • Return to your clinic every 8 weeks for repeat injections to maintain contraceptive protection.
  • Inform your healthcare provider if you are pregnant, planning pregnancy, or breastfeeding.
  • Nur-Isterate may interact with certain medicines (e.g., some TB or epilepsy drugs).

• Alternatives:

• • Oral contraceptive pills
  • Other injectable contraceptives (e.g., Depo-Provera every 12 weeks)
  • Implants, intrauterine devices (IUDs)
  • Barrier methods (condoms, diaphragm)
  • Permanent methods (tubal ligation, vasectomy)
• Always read the medication leaflet for full instructions and possible side effects.

Submitting this questionnaire 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.

If you require an invoice for medical aid, please fill out the below

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.