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REQUEST FOR EMERGENCY CONTRACEPTION PILLS Date of visit: Time of visit: AM / PM Client Name: DOB: Age: Address: Follow-up contact method: Emergency Contact: Relationship: Phone Number: Please complete
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How to fill out request for emergency contraception

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How to fill out a request for emergency contraception:

01
Obtain a request form from a healthcare provider or a local pharmacy. These forms are usually available for free and can be requested discreetly.
02
Carefully read through the instructions provided on the form. Make sure you understand the requirements and the information that needs to be provided.
03
Fill out your personal details accurately. This includes your full name, date of birth, contact information, and any relevant medical history.
04
Indicate the date and time of the incident that led to the need for emergency contraception. Be as specific as possible to ensure accurate assessment and prompt action.
05
Provide information about any medications you are currently taking, as well as any known allergies or medical conditions. This will help the healthcare provider make an informed decision and provide appropriate advice.
06
If applicable, include details about any previous use of emergency contraception or any recent sexual encounters that could have led to the need for this form of contraception.
07
Sign and date the request form, confirming that the information provided is accurate and complete. Your signature indicates that you understand the purpose and potential risks of emergency contraception.

Who needs a request for emergency contraception?

01
People who have had unprotected sex or contraceptive failure, such as a broken condom or missed birth control pills, may need emergency contraception. It is crucial to act quickly, as emergency contraception is most effective when taken as soon as possible after unprotected intercourse.
02
Individuals who have experienced sexual assault or rape may also require emergency contraception. Seeking immediate medical attention and speaking to a healthcare provider or visiting a local pharmacy can help ensure the necessary support and access to emergency contraception.
03
People who have had consensual sexual encounters but did not use any form of contraception or faced an unexpected contraceptive failure should also consider obtaining emergency contraception.
Remember, emergency contraception is not intended as a regular form of birth control and should only be used in emergency situations. It is always best to consult with a healthcare professional or pharmacist for personalized advice and guidance.
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Emergency contraception is a form of birth control that can prevent pregnancy after unprotected sex or contraceptive failure.
Anyone who needs emergency contraception can request it.
To fill out a request for emergency contraception, one can visit a healthcare provider or a pharmacy.
The purpose of a request for emergency contraception is to prevent pregnancy after unprotected sex or contraceptive failure.
Typically, personal information such as name, date of birth, and medical history may need to be reported on the request for emergency contraception.
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