Contraceptive Pill Review / Request

If you have been advised by the surgery to submit a contraceptive pill review or request, please use this form.

Before prescribing you oral contraception, we will ask you some questions about your health – a GP will review your answers to ensure we prescribe safely.

Please allow minimum 3-5 working days for your prescription to be processed.

Contraceptive Pill Review / Request

Patient Details

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

About You

Please include pharmacy name, address and postcode

Blood Pressure

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Are you able to provide a blood pressure reading? *

Please use date format: DD/MM/YYYY

In Metres
In KG
Have you had any changes to your health since the last pill check? *

The progesterone only pill (POP) and Combined Oral Contraceptive (COCP) are taken daily and with typical use they are 91% effective preventing a pregnancy. Long acting contraception such as IUD(coil), implant and injections are better at preventing a pregnancy. None of these methods protect you against sexually transmitted infections such as herpes, chlamydia, HIV. If you are worried about STIs, for more info visit www.essexsexualhealthservice.org.uk or speak to your GP.

To read more about how the oral contraception works, their benefits, side effects and risks as well as alternative contraception options such as long acting contraception visit www.patient.info/health/contraception-methods

If you are having issues with your current contraception, please book an appointment with your GP to discuss your options further.

Before prescribing you oral contraception, we will ask you some questions about your health - a GP will review your answers to ensure we prescribe safely. Once you are prescribed the pill, it will be added to your repeat list for a total of 12 months which you can request online or via repeat prescription service in the surgery manually. After a year you will need to come back or fill a new form for a review unless there is any change earlier in your circumstances or you have any concerns.

Have you had a 'normal' period in the last 4-5 weeks? *
Please use date format: DD/MM/YYYY
Have you had unprotected sex since your last period? *
Have you experienced any unusual vaginal bleeding in the last 2 years? *
Have you been pregnant in the last 2 months? *
Has anyone in your close family (mother/father/brother/sister) had heart attack under the age of 50, a blood clot in legs or lung or stroke? *
Are you taking any prescription/ herbal medicine eg. St John’s Wort? *
Have you ever had breast cancer? *
Have you ever had gastro-intestinal (bowel) or gallbladder problems? *
Have you ever had liver problems or jaundice? *
Have you ever had a blood clot in legs or lung, a stroke or a heart condition? *
Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about? *
Have you ever suffered from migraines or developed any since using the pill? *
Do you smoke? *

If you wish to discuss any alternative contraception methods, please contact the practice to arrange an appointment.

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