Service Request Form – Emergency Contraception Service Request Form – Emergency Contraception Emergency Contraception Basic 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. (Most foreign nationals do not have TAJ card) I do not know my TAJ card number or I cannot upload a Copy of my TAJ Card nowTAJ 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, that you have a copy and can upload.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 NamePatient’s Given NameBirth 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 NameConfirm 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 – CountrySelect Country of BirthAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePlace of Birth – Town, CityDate of Birth, Year-Month-DayPermanent (Home) AddressStreet Name and NumberSupplemental Information about Home Address (e.g. c/o)City, TownState, County, RegionZip (Postal) CodeCountry of Permanent (Home) AddressSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweAdditional Address. Would you like to provide any other, such as Billing or Temporary address? Yes NoAdditional Address. Temporary stay, Hotel or other Accomodation. Billing Address if different from Home Address.Street Name and NumberSupplemental Information about Address (e.g. c/o)City, TownState, County, RegionZip (Postal) CodeCountry of Additional AddressSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmail 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 CodeLocal Phone/Mobile NumberDate, when you had the unprotected sexual intercourse that would need Emergency Contraception (Plan B). YYYY.mm.ddTime 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.ddHormonal 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 ContraceptionHave 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 NoSpecify 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 NoPast 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 occasionallyMedications 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 occasionallyAllergies 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).Have you used Emergency Contraception in the past? Yes NoDo you have any Drug Preference for Emergency Contraception? Yes. But I also realize, that the preferred drug may not be available in the local pharmacies. No. I will let the physician decide which drug best fits my needs and to be used.The Name and Dosage of Preferred Drug for Emergency Contraception.Other Important Information you would like us to know. Optional field.Additional File Upload – OptionalChoose 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 as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.Submit Form