Appendix 2

Emergency Hormonal Contraception Consultation form

For accredited pharmacists to issue levonorgestrel 1.5mg

For use with Community Pharmacy EHC PGD

Client Name

Reason for request [Tick one box]:Condom failure Missed pill

Previous tablet lost or vomited

within last three hoursNo contraception used  Other 

GP name and address ……………………………………………………………………………………………………………………………

Assessment of Fraser Competency for client between 13 and 16 years of age

Is the client between 13 and 16 years old? No Yes

1. Client understands advice given

2. Client encouraged to involve parents

or other responsible adult

3. Is action in the interest of the young person? 

4. Has effect of withholding treatment on physical  

and mental health of client been considered?

After consideration of the above conditions of the Fraser Guidelines:

Is it appropriate to continue the consultation?  

5. If attending for pregnancy test:

Was test carried out prior to issuing EHC: No

Yes

Result: Negative  Positive  Refer 

Batch no/expiry date

Ethnicity: White: British  Irish  Any other white background 

Mixed: White/Black Caribbean  White/Black African  White/Asian 

Any other background 

Asian or Asian British: Indian  Pakistani  Bangladeshi  Any other background 

Black or Black British: Caribbean  African  Any other background 

Other Ethnic Groups: Chinese  Any other ethnic group  Not stated 

Information to include in discussion with client [Tick when completed]

Reassurance given regarding confidentiality of consultation 

Chlamydia Screening: Client informed and understood about the

importance of Chlamydia screening after unprotected sex  Yes  No

Client accepted postal screening kit  Yes  No

If No, opt out form completed (Appendix 9) Yes  No

Why has the screen been declined? ………………………………………………………………………………………………………………

Provider of previous test ……………………………………Date …………………………..

Client returned completed Chlamydia screen to Pharmacy  YES  No

The EHC treatmentMode of actionRisks / benefits

Failure rateAdverse effects

What to do if vomiting occurs within three hours of taking a tablet

Indications for follow-up explained to client

Suspected pregnancy or absent period (If next period later than seven days

after due date, reattend for further pregnancy test or see other medical

professional for further test

Abnormal bleeding, severe or persistent abdominal pain

Further information

Importance of follow-up

On-going contraception/ safer sex advice (issue leaflets if appropriate) 

Provide Levenolle Patient information leaflet

Documentation completed; free condoms issued where applicable

Where did client hear about the asc service………………………………………………………………………….

Onward referral to:

Sexual and Reproductive Health Care Service (SHARC)  Bpas  One Stop Shop  ‘asc’ Support Worker  GP  GUM 

Other (please specify)…………………………………………………………………………………………………

Declaration by Pharmacist (Fill in as appropriate)

Time

1xLevonorgestrel 1.5mg oral tablet: Supplied Administered Administered……..

Batch number: Expiry:

Signpost to:

Referral to:

Other comments,

advice or

information given

I declare that I am a pharmacist accredited to issue levonorgestrel 1.5mg within Coventry tPCT. The action specified was based on the information given to me by the client, which, to the best of my knowledge, is correct. This is an accurate record of the consultation I conducted with this client.

Pharmacist’s Signature: …………………………………. Date: ……………………………..

Pharmacist’s name: ……………………………………….Pharmacy Stamp

RPSGB Number: ……………………………………………

Time taken for consultation ………………. Minutes

Pharmacist to retain a copy of this form in a safe secure place

Consultation Notes