Problems with EC at a Pharmacy?

Your Name:

Your Telephone Number:

Your Email Address:

The Patient’s Name if Different:

Pharmacy Name and City:

Name of Medical Provider who signed prescription:

If for Emergency Contraception, how long after the sexual encounter were you refused by the pharmacy?:

Date that service was refused:

Did you eventually find a pharmacy to serve you?:

Any other comments about your experience?

Thank you very much for your help.