Self-Administered Hormonal Contraception Protocol Information
Protocol for Pharmacists to Furnish Self-Administered Hormonal Contraception
- This protocol has been adopted as Title 16, California Code of Regulations section 1746.1
- The underlying reference statute is California Business and Professions Code section 4052.3
- Center for Disease Control and Prevention’s United States Medical Eligibility Criteria (USMEC)
Patient-Self-Screening Tool
The patient must be asked to complete the self-screening tool to identify patient risk factors before the pharmacist initiates discussing self-administered hormonal contraception.
- Patient Self-Screening Tool - English
- Patient Self-Screening Tool - Korean
- Patient Self-Screening Tool - Russian
- Patient Self-Screening Tool - Spanish
- Patient Self-Screening Tool - Tagalog
- Patient Self-Screening Tool - Traditional Chinese
- Patient Self-Screening Tool - Vietnamese
Patient Education Leaflet
The pharmacist must provide a patient education leaflet for the specific contraception provided to a patient on the appropriate method for using the drug, the need for medical follow up, and other appropriate information.