{"id":149,"date":"2021-03-15T14:14:08","date_gmt":"2021-03-15T14:14:08","guid":{"rendered":"https:\/\/mcfaddenspharmacy.ie\/?page_id=149"},"modified":"2021-09-01T10:29:00","modified_gmt":"2021-09-01T10:29:00","slug":"morning-after-pill-form","status":"publish","type":"page","link":"https:\/\/mcfaddenspharmacy.ie\/morning-after-pill-form\/","title":{"rendered":"Morning After Pill Form"},"content":{"rendered":"<section class=\"kc-elm kc-css-3892 kc_row form-style1\"><div class=\"kc-row-container  kc-container\"><div class=\"kc-wrap-columns\"><div class=\"kc-elm kc-css-398011 kc_col-sm-12 kc_column kc_col-sm-12\"><div class=\"kc-col-container\"><div class=\"kc-elm kc-css-78957 kc_text_block\"><\/p>\n<p><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script><\/p>\n<div class='gf_browser_safari gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' >\n<div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n<form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/149#gf_2' data-formid='2' novalidate>\n<div class='gform-body gform_body'>\n<ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<li id=\"field_2_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" >This online form will save you time on your visit to McFadden\u2019s Pharmacy. If you request the pharmacist to call you, most of the consultation can occur by phone before you visit the store. Otherwise the pharmacist will have your form ready and they will have a private consultation with you in the store. This takes a few minutes to complete.<\/li>\n<li id=\"field_2_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\" ><label class='gfield_label gform-field-label' for='input_2_6'>Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_text'><input name='input_6' id='input_2_6' type='text' value='' class='medium'   tabindex='49'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label' for='input_2_5'>Your address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='' class='medium'   tabindex='50'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_7\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\" ><label class='gfield_label gform-field-label' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>\n<div class='gfield_description' id='gfield_description_2_7'>This service is open to women over the age of 17 years old. If you are under 17 please call the pharmacy to discuss your options.<\/div>\n<div id='input_2_7' class='ginput_container ginput_complex gform-grid-row'>\n<div class=\"clear-multi\">\n<div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_2_7_2_container'><select name='input_7[]' id='input_2_7_2' tabindex='51'  aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div>\n<div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_2_7_1_container'><select name='input_7[]' id='input_2_7_1' tabindex='52'  aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div>\n<div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_2_7_3_container'><select name='input_7[]' id='input_2_7_3' tabindex='53'  aria-required='true'  ><option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div>\n<\/div>\n<\/div>\n<\/li>\n<li id=\"field_2_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\" ><label class='gfield_label gform-field-label' for='input_2_8'>If you have a Medical Card please enter your number here (Alternatively you can bring your medical card with you to the pharmacy)<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'   tabindex='54'   aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_9\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' >Time since unprotected sex<\/label>\n<div class='gfield_description' id='gfield_description_2_9'>This helps us to choose the correct product. One of the products can be taken up to 5 days (120 hours) after unprotected sex, but with all emergency contraceptives the sooner emergency contraception is taken the more effective it is.<\/div>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_9'>\n<li class='gchoice gchoice_2_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='0-72 hrs'  id='choice_2_9_0' tabindex='55'   \/><br \/>\n\t\t\t\t<label for='choice_2_9_0' id='label_2_9_0' class='gform-field-label gform-field-label--type-inline'>0-72 hrs<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='72-120 hrs'  id='choice_2_9_1' tabindex='56'   \/><br \/>\n\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>72-120 hrs<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_9_2'>\n\t\t\t\t<input name='input_9' type='radio' value='over 120 hrs'  id='choice_2_9_2' tabindex='57'   \/><br \/>\n\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>over 120 hrs<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_10\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" >\n<h3>ADDITIONAL INFORMATION<\/h3>\n<\/li>\n<li id=\"field_2_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\" ><label class='gfield_label gform-field-label' for='input_2_11'>Current day of menstrual cycle? (The first day of your last period is day one).<\/label>\n<div class='gfield_description' id='gfield_description_2_11'>This helps the pharmacist establish the risk of pregnancy. Leave blank if unknown.<\/div>\n<div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_11\" tabindex='58'   aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label' >Is the medication for your own use?<\/label>\n<div class='gfield_description' id='gfield_description_2_13'>Customers must attend in person to collect the morning after pill.<\/div>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_13'>\n<li class='gchoice gchoice_2_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_2_13_0' tabindex='59'   \/><br \/>\n\t\t\t\t<label for='choice_2_13_0' id='label_2_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_2_13_1' tabindex='60'   \/><br \/>\n\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_14\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label' >Is there any chance you may already be pregnant before this episode of unprotected sex?<\/label>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_14'>\n<li class='gchoice gchoice_2_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_2_14_0' tabindex='61'   \/><br \/>\n\t\t\t\t<label for='choice_2_14_0' id='label_2_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_2_14_1' tabindex='62'   \/><br \/>\n\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Don&#039;t know'  id='choice_2_14_2' tabindex='63'   \/><br \/>\n\t\t\t\t<label for='choice_2_14_2' id='label_2_14_2' class='gform-field-label gform-field-label--type-inline'>Don't know<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label' >Will this be the first time you have used Emergency Contraception since your last period?<\/label>\n<div class='gfield_description' id='gfield_description_2_15'>Emergency contraception can be taken more than once in a cycle, but the pharmacist needs to know this, so they can select the most appropriate product.<\/div>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_15'>\n<li class='gchoice gchoice_2_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_2_15_0' tabindex='64'   \/><br \/>\n\t\t\t\t<label for='choice_2_15_0' id='label_2_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_2_15_1' tabindex='65'   \/><br \/>\n\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_16\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><label class='gfield_label gform-field-label' >Are you breastfeeding?<\/label>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_16'>\n<li class='gchoice gchoice_2_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_2_16_0' tabindex='66'   \/><br \/>\n\t\t\t\t<label for='choice_2_16_0' id='label_2_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_2_16_1' tabindex='67'   \/><br \/>\n\t\t\t\t<label for='choice_2_16_1' id='label_2_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_17\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" >\n<h3>OTHER MEDICATION<\/h3>\n<p>Some customers are on medication that could make the morning after pill less effective. The following questions help the pharmacist establish the best emergency contraception option for you:<\/li>\n<li id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\" ><label class='gfield_label gform-field-label' >Are you taking any medication, including any contraceptive methods?<\/label>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_18'>\n<li class='gchoice gchoice_2_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_2_18_0' tabindex='68'   \/><br \/>\n\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_2_18_1' tabindex='69'   \/><br \/>\n\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_19\" class=\"gfield gfield--type-text if-yes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_19'>If Yes, please specify<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'   tabindex='70' placeholder='If Yes, please specify'  aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_20\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\" ><label class='gfield_label gform-field-label' >Do you suffer from any illnesses, conditions or allergies?<\/label>\n<div class='ginput_container ginput_container_radio'>\n<ul class='gfield_radio' id='input_2_20'>\n<li class='gchoice gchoice_2_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_2_20_0' tabindex='71'   \/><br \/>\n\t\t\t\t<label for='choice_2_20_0' id='label_2_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n<li class='gchoice gchoice_2_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_2_20_1' tabindex='72'   \/><br \/>\n\t\t\t\t<label for='choice_2_20_1' id='label_2_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_21\" class=\"gfield gfield--type-text if-yes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_21'>If Yes, please list here<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'   tabindex='73' placeholder='If Yes, please list here'  aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_24\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" >\n<div style=\"margin-top:30px;\"><\/div>\n<h3>WHAT HAPPENS NEXT?<\/h3>\n<p>Once you click submit, the pharmacy will receive your details. The pharmacist will review the information and prepare for your consultation. If you request a phone consultation by entering your phone number below the pharmacist will call you to carry out the consultation over the phone. Your medication will be ready for collection within 1 hour (during store opening hours). You will still need to come to the pharmacy yourself to collect the medication.<\/li>\n<li id=\"field_2_25\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_25'>Phone<\/label>\n<div class='gfield_description' id='gfield_description_2_25'>\n<h4>Contact Phone Number<\/h4>\n<p>By entering your phone number here you are consenting to the pharmacist contacting you by phone to carry out a consultation. (If you do not consent to being contacted and want to complete the consultation in store, please leave this question blank)<\/p><\/div>\n<div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_25\" tabindex='74' placeholder='Phone'  aria-invalid=\"false\"   \/> <\/div>\n<\/li>\n<li id=\"field_2_26\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_26'>\n<li class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that McFadden\u2019s Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.'  id='choice_2_26_1' tabindex='75'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>I confirm that the information I have given is correct to the best of my knowledge. I am aware that I will need to attend the pharmacy in person and to speak with the pharmacist before emergency contraception will be supplied. I am aware that McFadden\u2019s Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id=\"field_2_27\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" >\n<div style=\"margin:30px auto 0; width:80%\">\n<p><em>*If you have a medical card please bring it to the pharmacy with you when collecting your medication.<\/em><\/p>\n<\/div>\n<\/li>\n<\/ul>\n<\/div>\n<div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit' tabindex='76' onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); 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