Contraceptive Pill Review

You only need to fill this form if you have not had a review within the last year.

If you have had a review (either with a clinician or via this form) within the last 12 months, you can request a repeat prescription on the repeat prescription form.

If you are having any problems with your medication or would like to consider alternative contraception options, please book a telephone appointment with a GP.

If there are any problems with re-issuing your prescription we will contact you. Your prescription will be ready for you to collect within 3 working days either from reception or directly from the pharmacy if you have set up electronic prescriptions.

Please remember to read the patient leaflet provided with your pills.

The contraceptive pill may not work if taken incorrectly/missed, you have diarrhoea, have been vomiting or are on some types of antibiotics.

The contraceptive pill does not protect you from sexually transmitted infections, condoms should be used to protect yourself.

Contraceptive Pill Review

Name

Date of Birth (DD.MM.YYYY)

Phone Number

Current contraceptive pill

Recent blood pressure reading

Current weight

Current height

Are you pregnant or breastfeeding?

Do you smoke?

If yes, how many a day?

Do you suffer from migraines that cause visual symptoms or changes in sensation or muscle power on one side of your body?

Do you have parents or siblings who have had heart disease or strokes under the age of 45?

Have you had a blood clot, deep vein thrombosis or pulmonary embolus?

Do you have parents or siblings that have had a blood clot, deep vein thrombosis or pulmonary embolus?

Have you had breast cancer?

Do you have any family history of breast cancer under the age of 50?

Do you have any long distance travel or surgical operations planned?

Do you suffer from irregular bleeding?

Have you started any new medication since we last issued you a prescription for the pill?

Have you been diagnosed with any new health conditions since we last issued you a prescription for the pill?

If yes, please provide details

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Shotfield Medical Practice • Shotfield, Wallington, Surrey, SM6 0HY.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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