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Contraceptive Review Form

This form is for women already established on a contraceptive pill.

Please complete the form as fully as possible. This is to ensure patient safety. We are unable to process prescription requests without an up to date height, weight or blood pressure. Once your form has been processed, a prescription will be issued for 12 months supply of your medication – please ensure you collect the total balance from the pharmacy.

Please read information on blood clots.

If a prescription is not issued we will contact you to let you know.

Contraceptive Review
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
Do you smoke?
Have you or any of your immediate family (parents or siblings) ever been diagnosed with a blood clot in the leg (DVT) or a blood clot in the lungs (Pulmonary embolism)?
Are you aware you should tell a healthcare professional that you are on the pill if you have an operation or a prolonged period of immobilisation i.e. leg in plaster?
Do you understand that the symptoms of blood clots can include shortness of breath, sharp chest pain, coughing up blood, calf pain and swelling?
Do you know that the risk of a clot increases with combined pills if you travel for extended periods ie long haul flights?
Please indicate if you have experienced or been diagnosed with any of the following conditions in the past 12 months?
Please indicate if you are currently taking any of the following medications?
Do you suffer from migraine with aura?
Have you had any unexplained vaginal bleeding, bleeding in between periods or bleeding after sex?
If you are over 25, is your cervical screening up to date?
Do you know what to do if you miss a pill?
Would you like to discuss long acting reversible contraception?
Please be aware contraceptive pills and injectables do not protect against sexually transmitted diseases.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.