JAPAN NET CLINIC · BeautyOn Clinic Ginza

Emergency contraception: medical questionnaire and consent

Write ‘unknown’ if unsure and ‘none’ where not applicable. The clinician determines suitability and the prescription. Do not delay seeking care to complete this form. Entries are not automatically sent or saved. Print or save as PDF and show it at your consultation.

01 · Patient questionnaire

Full nameDate of birthContact details / emailDates and times of ALL unprotected intercourse or contraceptive failures (include time zones)Contraceptive method and what went wrongFirst day of last period / usual cycle / delayed periodPossible pregnancy / pregnancy test date and resultBreastfeedingCurrent and past conditions (including liver, kidney, heart or digestive/absorption disorders)Medicine or food allergies and reactionsALL medicines, contraceptives, herbal products and supplementsEmergency contraception taken during this cycle (name and date)Current symptoms (abdominal pain, bleeding, vomiting, etc.)Other information / questions

JAPAN NET CLINIC · BeautyOn Clinic Ginza

02 · Clinician explanation and record

Emergency contraceptive pills help prevent pregnancy; they do not end an established pregnancy and are not 100% effective.
The time window depends on the medicine. Seek care promptly; even if time has passed, contact a clinician rather than giving up or waiting.
Nausea, tiredness or irregular bleeding may occur. If you vomit after taking the medicine, promptly ask a clinician whether another dose is needed.
They do not protect later intercourse or prevent sexually transmitted infections. Follow the clinician’s pregnancy-check instructions and seek advice for a late period or suspected pregnancy. Severe abdominal pain, fainting or heavy bleeding requires urgent care.

Prescribed product, ingredient, dose, timing and instructionsSubsequent contraception, pregnancy check/follow-up and action if vomitingIndividual risks, interactions, alternatives and answers to questionsExplaining clinician / interpreter or support person (if applicable)

03 · Acknowledgement and consent

The information I have provided is accurate to the best of my knowledge. The clinician has explained the medicine, instructions, limitations of effectiveness, side effects, alternatives, precautions and follow-up. I have had the opportunity to ask questions, understand the explanation, and voluntarily consent to the consultation and the medicine explained to me.

Patient signatureDate and time signed

WHO · Emergency contraception · PMDA · Levonorgestrel patient information

03-6281-4250 · 11F, HULIC & New GINZA 8, 8-9-7 Ginza, Chuo-ku, Tokyo
Version 2026-11-12