Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.

Your Current Health Details

In KG
In M
in mmHg
in mmHg
in BPM

Your Medical History

(e.g. Deep Vein Thrombosis or Pulmonary Embolism)
Please select all that apply

Alternative Contraception

(e.g. contraceptive implant or coil)

Alcohol and Smoking Questions

For further information, please see www.nhs.uk/smokefree

Further Information

After completing all of the above questionnaire, please click submit below. Your GP practice will then inform you if your oral contraception repeat prescription is ready for collection or if a further assessment is required.