If you are planning a holiday, special occasion or other important event and would like to delay your period, you can use this form to request medroxyprogesterone, if it is suitable for you.

If you would like more information about period-delaying medication, including how it works, who it is suitable for, how to take it and possible side effects, please click here.

Please complete this form as accurately as possible. A clinician will review your request to determine whether this medication is safe and appropriate for you based on your medical history, current medications and any potential risk factors. You may be contacted if any further information is required.

Please note that submitting this form does not guarantee that a prescription will be issued. Medroxyprogesterone is not suitable for everyone, and a clinician will assess whether it is appropriate for you.

To allow sufficient time for your request to be reviewed, please submit this form at least 2 weeks before you wish to delay your period.