Terms of use "Emergency contraception" consultation

The patient declares that she contacted the doctor on her behalf, I did not conceal any facts (she is aware that misleading the doctor may have a negative impact on her life and health) and that she acts of her own free will and a remote medical consultation is carried out at her request in connection with an emergency (urgent consultation is necessary and it was not possible to make an appointment to see a doctor in person).
The patient declares that she is aware that the consultation is only aimed at obtaining a prescription for emergency contraception.
The patient declares that she has been informed that emergency contraception must not be used during pregnancy.
The patient declares that she has been informed that no drug is 100% effective in preventing pregnancy and that in the event of delayed menstruation, a pregnancy test should be performed, and in the event of a positive result, she should visit a gynecologist and inform him that she has taken emergency contraception.
The patient declares that she has been informed that she should immediately report to her gynecologist for a checkup. If you are unsure about your partner’s health, please also inform your doctor about your exposure to sexually transmitted diseases.
Is aware that a physician may refuse to issue a prescription if in doubt about safety in the case of their use. In such a situation, he will be informed by phone and the consultation fee will be refunded in full.
The patient declares that she has been informed that in the event of pregnancy, the applied treatment may increase the risk of ectopic pregnancy.
The patient declares that she has been informed that obesity may entail a risk that the emergency contraception will be less effective.
The patient declares that she has been informed to read the package leaflet before taking any medications.
The patient declares that she has not taken any emergency tablets during this menstrual cycle
The patient declares that she has been informed that taking certain medications may entail the risk of significantly lower effectiveness of the emergency contraceptive used, e.g. barbiturany (w tym prymidon (Mizodin) i fenobarbital (Luminal)), fenytoina (Phenytoinum WZF), fosfenytoina, karbamazepina (Amizepin, Finlepsin, Neurotop Retard, Tegretol), okskarbazepina (Karbagen, Oxcarbazepin, Oxepilax, Trileptal), herbal remedies containing St. John’s wort
(Hypericum perforatum), ryfampicyna (Rifamazid, Rifampicyna TZF), ryfabutyna, gryzeofulwina, efawirenz (Atripla) and newirapina(Viramune, Nevirapine Accord).
The patient declares that she has been informed that in the event of disturbing symptoms, she should visit a primary care physician and in the event of severe abdominal pain or bleeding, she should visit a hospital with a gynecological department.