Oral Contraceptive Report Form

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In accordance with Act 408 of 2021, please report the following information to the Department of Health: (i) The number of women who receive oral contraceptives without a prescription; and (ii) The age of the women who receive oral contraceptives without a prescription.

In the fields below, please enter the first and last date of the reporting period.

Start Date:

End Date:

Please enter your pharmacist license number in the field below:

In the field below, please enter the total number of women to whom oral contraceptives were distributed without prescription between

______ and ______.

In the area below, please provide the aggregate counts of the number of women to whom oral contraceptives were distributed without prescription by age (at the time the prescription was distributed).

The default value for each response is zero. Please only fill in boxes for which you have distributed oral contraceptives without a prescription.

18 Years Old:

19 Years Old:

20 Years Old:

21 Years Old:

22 Years Old:

23 Years Old:

24 Years Old:

25 Years Old:

26 Years Old:

27 Years Old:

28 Years Old:

29 Years Old:

30 Years Old:

31 Years Old:

32 Years Old:

33 Years Old:

34 Years Old:

35 Years Old:

36 Years Old:

37 Years Old:

38 Years Old:

39 Years Old:

40 Years Old:

41 Years Old:

42 Years Old:

43 Years Old:

44 Years Old:

45 Years Old:

46 Years Old:

47 Years Old:

48 Years Old:

49 Years Old:

50 Years Old:

51 Years Old:

52 Years Old:

53 Years Old:

54 Years Old:

55 Years Old:

56 Years Old:

57 Years Old:

58 Years Old:

59 Years Old:

60 Years Old:

61 Years Old:

62 Years Old:

63 Years Old:

64 Years Old:

65 Years or Older:

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