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Repeat Contraceptive Pill/Patch/Injection Form

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Personal Details

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Questions

Have you noticed any side effects: *

Do you have any allergies?: *

Do you have migraines?: *

In Metres

In Kilograms

Have you recently had a heart attack, stroke, raised cholesterol or diabetes?: *

Have you recently been diagnosed with any form of cancer? (eg breast, liver): *

Has anyone in your family been diagnosed with cancer since your last review? (eg breast): *

Since your last review have you or anyone in you family had a blood clot (eg DVT or PE): *

Do you have an up to date blood pressure within the last year? (We accept blood pressures taken at home): *

How would you describe your smoking status: *

Have you given birth in the last year?: *

Are you currently breast feeding?: *

Do you have any concerns regarding your bleeding pattern?: *

Do you have any concerns regarding vaginal discharge?: *

Are you happy with your prescription or would you like to discuss other options?: *

Please allow 5 working days from submission of this form before a prescription is sent to the pharmacy.

Your answers will be reviewed by the practice nurse team and if necessary they will phone you to discuss any issues further.

If no issue(s) are raised they routinely send a SMS to your mobile to let you know that prescription has been sent to the chemist.

Are you happy for them to confirm this with you via SMS: *

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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