Period Delay Requests – Court Road Surgery

Periods are a normal and healthy part of life as a female. There are a number of ways to delay your period for a holiday or special event.

We have seen an increasing number of requests for a GP consultation for patients travelling, particularly in the summer, wishing to delay their period. We have created this form so that requests can be made without an appointment keeping our GP appointment requests for those with medical needs.

When requesting medication to delay a period, all patients will be directed to the online form. We will reply within 5 working days. Please avoid having a request for an appointment being denied by completing the form.

Further information can be found at:

Guidance from NHS.uk

Guidance from Patient Info UK

Period Delay Medication for Travel

Medication to delay a period for travel may not be suitable for everyone, for example if you have breast cancer or a history of blood clots. How well it works in delaying periods also varies between women. Completion of this form does not guarantee that you will be prescribed medication to stop the pill but provides us with the information we need to make a decision about whether this is an appropriate choice for you without taking us away for dealing with patients who are unwell.

Name(Required)
First Last
Date of Birth(Required)
DD slash MM slash YYYY
Height(Required)
Weight(Required)
Smoking Status(Required)
- Never Smoked
- Current Smoker
- Ex Smoker
The Doctors in the practice do not recommend smoking. For help to quit please contact the HelpMe Quit Team on 0800 085 22119
When are you Travelling(Required)
DD slash MM slash YYYY
How long are you Travelling for?(Required)
Are you using Contraception?(Required)
- Yes
- No
Medical Questions
Please tick if the answer is YES to any of the questions below
- Do you, or have you ever, suffered with MIGRAINES?
- Do you have a history or, or family history of BLOOD CLOTS?
- Do you require Contraception?
Mobile Phone Number(Required)
Court Road Surgery aims to utilise text messages for a number of purposes including, but not limited to: Notification of cancellation of appointments, booking appointments, test results, forms ready for collection, invitations to reviews or clinics. It will be the responsibility of patients to ensure that telephone contact numbers are kept up to date.
Consent(Required)
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.