To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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- You are between ages of 18 – 50 years old.

- You are requesting this medicine for low fertility.

- You are not planning to undergo IVF treatment.

- You are not currently pregnant, breastfeeding, think you may be pregnant, or planning to have a baby.

- You have been actively attempting to conceive for the past 1 year (under 36 years of age).




Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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Never
Occasionally
Regularly




Rarely
1-2 times per week
3-4 times per week
Daily

If yes, please confirm what diagnosed condition is being treated with Clomifene.



If yes, please provide more information on what treatments.

If yes, please provide more information.



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Risks include:

- Increased risk of multiple pregnancies

- Ovarian hyperstimulation syndrome (OHSS)

- Vision changes (rare side effect)

- Slightly higher risk of ectopic pregnancy

- Mood swings and emotional changes

 

Benefits include:

- Increased ovulation

- Improved chances of pregnancy



- I am between the ages of 18 and 50

- This treatment is for my use only

- I have the capacity to make decisions about my own healthcare

- I have understood all the questions and have answered this consultation truthfully and completely

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health

- I will read the patient information leaflet supplied with this medication

- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health

- I have read, understood and agree with our Terms and Conditions