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Contraceptive Pill Review

All of this form needs to be completed before you prescription will be issued and you may still require a face to face/telephone appointment if it is felt necessary. Please complete this form at least 2 weeks before your prescription is due.

For information on contraception please visit the Contraception Guide on

All sections must be completed as a minimum standard. A blood pressure reading must be provided.

Contraceptive Pill Review
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979

Contraception Pill Review

Please take 3 readings and provide the best
Have you had any problems with your pill? *
Have you missed any pills during this last prescription period? *
Do you suffer from migraines? *
Do you have any personal or Family History of blood clots? *
Are you a smoker? *
If the answer to any of these questions is yes, then please book an appointment with a Family Planning Trained Nurse.
Have you had any other medical problems since your last prescription? *
Are you happy for communications regarding this prescription to be sent by text from the surgery? *

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.