Service Request Form - Emergency Contraception in Office

Service Request Form – Emergency Contraception in Office

Emergency Contraception Office

TAJ Card Information. Hungarian National Health Insurance will NOT be accepted for payment. However, TAJ Card Number may greatly simplify issuing and filling Electronic Prescriptions.

I have my TAJ Card Number and I can upload a Copy of my TAJ Card

I do not have a TAJ card number

I do not know my TAJ card number or I cannot upload a Copy of my TAJ Card now

TAJ Card Number – 9 digits.

Upload a Copy of your TAJ Card!

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Photo Identification Document, preferably Passport, alternatively Local Residence Permit, Country’s National Identification Card or Driver License Serial Number.

Upload a Copy of the Data Page of your Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Patient’s Family Name

Patient’s Given Name

Birth Name. Is your Name now the same that you had on your Birth Certificate?

Yes, my name is the same that I had at Birth.

No, I had a name change since Birth due to marriage, voluntarily or for other reasons.

Birth Name (Family)

Birth Name (Given)

Mother’s Maiden Last Name

Mother’s Maiden First Name

Confirm your Gender – in Hungary only Male or Female Genders are officially recognized.

Male. Not entitled for Emergency Contraception.

Female. Emergency Contraception is available.

Place of Birth – Country

Place of Birth – Town, City

Date of Birth, Year-Month-Day

Permanent (Home) Address

Street Name and Number

Supplemental Information about Home Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Additional Address. Would you like to provide any other, such as Billing or Temporary address?

Yes

Additional Address. Temporary stay, Hotel or other Accomodation. Billing Address if different from Home Address.

Street Name and Number

Supplemental Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Additional Address

Email Address that you want to use for Urgent and Confidential Communication.

Confirm the Email Address that you want to use for Urgent and Confidential Communication.

Mobile Phone number with Country Code

Local Phone/Mobile Number

Date, when you had the unprotected sexual intercourse that would need Emergency Contraception (Plan B). YYYY.mm.dd

Time on that day, when you had the unprotected sexual intercourse that would need emergency contraception. We use 24-hour system in CET.

First Day of Your Last Menstrual Period. YYYY.mm.dd

Hormonal Contraception (Pregnancy Prevention)

Yes, I use hormonal contraceptive, tablets or other form (e.g. depo injection, hormone releasing IUD).

No, I do not use hormonal contraceptive medications, or hormone releasing IUD.

Exact Form, Name and Dosage of Hormonal Contraception

Have you ever had the listed Medical Conditions, that may elevate the Complication Risk when using the requested Hormonal Emergency Contraception: Blood Clot Formation, Thrombosis, Embolism, Vascular Occlusion, Liver disease, tumors, cancer, Severe Migraine with weakness or neurological deficit, such as dizziness, change in level of conscioussness.

Yes

Specify Medical Conditions, that may eleveate the Complication risk when using Hormonal Emergency Contraception. You may choose 0-3.

Blood Clot Formation, Thrombosis, Embolism, Vascular Occlusion

Liver disease, tumors, cancer

Severe Migraine with weakness or neurological deficit, such as dizziness, change in level of conscioussness.

Medical Information. Have you had any Prior Illnesses, Hospitalizations, Surgeries?

Yes

Past Medical History. Chronic Diseases, Hospitalizations and Surgeries.

File Upload – Optional. You may attach additional document copies, such as medical reports, lab or imaging testing, prescriptions, immunization cards.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Current and Regular Medications and Treatments

I do not take any medications now and I do not have any regular prescribed treatments.

I take medications now or occasionally

Medications and Treatments. You may choose any or all of the listed.

I am being treated only now with some medications, but I do not take them regularly.

I take certain medications regularly (for a chronic condition or disease).

I only occasionally, but not daily take some medications (for example as needed for headache, backpain).

Exact Name and Dosage of Current but not Regular Drugs and other Treatments.

Exact Name and Dosage of Regular (Daily) Drugs and other Treatments

Exact Name and Dosage of Drugs and Treatments you may use occasionally

Allergies and Adverse Drug Reactions

No known drug allergies or adverse reactions.

I had allergies or adverse reactions to drugs.

Specify what exactly happened when you took the medication in question causing Allergy (e.g. skin rash, wheels, breathing problem, shock, anaphylaxis).

Other Important Information you would like us to know. Optional field.

Additional File Upload – Optional

Choose File (pdf, jpeg, jpg, png, bmp, gif)

I have read and agree to the Emergency Contraception Information Page a, the General Terms and Conditions and Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when I was not available for the requested and scheduled visits, according to the Payment Terms and Conditions.

Signature – Type your full name here to confirm your Identity!