Your First Name※Required

Your Last name※Required

Email Address※Required

Phone Number※Required

Date of Birth※Required

Postal Code※Required


【Common Questionnaire】

Recent menstrual period※Required

From... to around…

Menstrual cycle※Required

Days between periods

Please write down any questions you would like to ask during the examination.

Further inquiries
Please respond to the questionnaire that corresponds to
'Low-dose Pill Consultation,' 'Emergency Contraceptive Consultation,' or 'Thrombosis Symptoms Consultation.

【Low-dose Pill Consultation】

Have you ever used the pill?

What pills have you used so far?

What is your reason for using the pill?

Do you currently have any of the following symptoms ?

【After Pill Questionnaire】

Have you ever used the pill?

Currently, how many hours have passed since intercourse?

【Questionnaire about thrombosis symptoms at the 3-month checkup】

What symptoms do you have?