Form - BCP – DIMA

You're just a few questions away from getting your Birth Control!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

We cannot prescribe birth control to you if you are under 18.

What was your latest blood pressure reading in the last 6 months? Generated Image

Low

Normal

High

Very High

Do you have Hypertension?

Yes, but its under control

Yes, and difficult to manage

No

Please select the situations and conditions that apply to you.

If you have any medical conditions not listed previously, please list them below.

Please select the medications you are currently taking.

John`s Wort or oral fungal treatment

Anticonvulsants or medications for nerve pain or bipolar disorder, containing carbamazepine, phenytoin, primidone, topiramate, oxcarbazepine, or lamotrigine

Antibiotics containing rifampin or Rifabutin

Barbiturates

Fosamprenavir

None of the above

If you are taking any other medicines or supplements not listed in the previous questions please list them below.

Please select the following menstrual issues that apply to you.

Abnormal vaginal bleeding different from your usual period

Periods have become more frequent or heavier than your usual period

Abnormal bleeding between your periods

None of the above

Are you allergic to any medicines? If yes, please list them below.

Thank you for filling the form!

You can now select products you want to add to your cart: