Lovima checklist: is desogestrel right for you?

How old are you? *

Under 16

17-18

19-55

If you are under 16, please consult your pharmacist

Could you be pregnant? *

Yes

No

If you think you are pregnant, we recommend that you see a doctor

Do you have any of the following? A thrombosis (blood clot) or any of the symptoms eg. severe pain in the leg or lungs? Diabetes? History of jaundice (yellowing of the skin), liver disease or liver cancer? Any history or suspect you have breast, uterine, endometrial, or ovarian cancer, or any other hormone sensitive cancer? Any unexplained vaginal bleeding? *

Yes

No

We recommend that you speak to your doctor first to make sure that Lovima is right for you.

Do you have any allergies? *

Yes

No

Are you taking any medication? *

Yes

No

If you wish to have the form emailed to you upon submission, select Yes below and then enter your email address in the box provided *

Yes

No

If you select No, your form will only be available to download from the next page, after you click the submit button.