Contraception (The Pill) Oral or Patch

1. 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.
2. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.
3. I agree to the Terms & Conditions of this platform.
4. I am 18 years or older.
5. I am currently living in South Africa.
6. I will have an in-person medical consultation at least once a year for comprehensive care and physical examination.
7. I acknowledge that a doctor will communicate with me via WhatsApp within 24 hours.

Please remember the following when using contraceptive medications:

• 💊Oral & Patch contraceptives are over 99% effective in preventing pregnancy when used as prescribed. It's crucial to take your pill daily as directed. If you miss a pill, follow the instructions on the medication pamphlet.

• 😷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.

• 🚭Get regular breast examinations and regularly self-examine yourself and visit an in-person doctor if you feel any lumps. Look in the mirror for changes, then feel all areas in circles (lying down & standing up). Regularly monitor your blood pressure, have pap smears at the recommended intervals and avoid smoking.

Consent:

• Purpose of Treatment: Oral contraceptive pill for the purpose of preventing pregnancy.

• How to use: Take one pill every day at the same time. If a pill is missed, follow the instructions provided by my doctor or pharmacist. No protection against sexually transmitted infections (STIs) - condoms are recommended if STI protection is required.

• Expected Outcomes: Highly effective contraception if taken correctly and consistently. Fertility usually returns quickly once the pill is stopped.

• Possible Side Effects:

• Common:

• • • Nausea, breast tenderness, bloating
    • Irregular spotting or breakthrough bleeding (especially in the first few months)
    • Headaches or mood changes
    • Mild weight fluctuations
  • Less Common:
    • High blood pressure
    • Skin changes (acne, pigmentation)
  • Rare but important (seek medical attention immediately):
    • Blood clots (deep vein thrombosis, pulmonary embolism) - warning signs include calf pain/swelling, chest pain, sudden shortness of breath
    • Stroke or heart attack (rare, more likely if smoking or with certain health risks)
    • Liver problems (jaundice, severe abdominal pain
    • Combined hormonal contraception may slightly increase the risk of breast cancer

• Alternatives:

• • Injectable contraception
  • 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.