To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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If yes, please provide details

Deep vein thrombosis (DVT) and Pulmonary embolism

If yes, please provide details

Angina and heart attack





E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency

If yes, please provide details





If yes, please provide details

Papilloedema and Retinal vascular lesions

If yes, please provide details

Please provide details in this box here...

Migraines / Epilepsy / Asthma

Systemic lupus erythematosus / Severe obesity (BMI >30 kg/m2) / Thromboembolism / Recurrent miscarriage


If yes, please provide details

If yes, please provide details









Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
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