Contraceptive Pill Review

Please ONLY complete this form if advised by the Practice.

You will need to obtain a Blood Pressure Reading prior to submitting this form.

Blood Pressure Readings can be obtained from our patient self-service unit in our Practice waiting area if you don’t have your own unit.

Enter your BP reading on the form and complete the remaining questions, then submit the form.

Our Women’s Health Nurse will review your form.  If everything is normal your prescription should be able to be renewed without a further appointment.  Should an appointment be required we will contact you, normally by Text message.

Contraceptive Pill Review

Contraceptive Pill Review

Patient Details

You need to obtain a Blood Pressure Reading to submit this form. Blood Pressure Readings can be obtained from our patient self-service unit in our Practice waiting area if you don’t have your own unit.

Please use the name on your patient records
Please use date format DD/MM/YYYY
All correspondence will go to this address.

 

Please enter your Blood Pressure reading taken from our self-service unit or your own Blood Pressure machine if you have one.

This should be the same day you submit this form.

Please use Kilograms (KG).
Please use centimetres (CM)
For more information, please refer to the email we will send you about your contraceptive pill or the information leaflet that comes with your pill.
For more information, please refer to the email we will send you about your contraceptive pill or the information leaflet that comes with your pill.
Please use format DD/MM/YYYY
You should have a sexual health check when you start having sex with a new partner.
For example, heart attack, angina, chest pain on exertion, abnormal heart rhythm, valve problem or a problem with your heart since birth.
For example, a pulmonary embolism (PE) or deep vein thrombosis (DVT).
For example, a breast lump, skin changes or nipple discharge.
For example, have you been bed-bound, used a wheelchair or broken a leg? This may increase your risk of blood clots and stroke.
This includes any herbal remedies or over the counter medicines such as St John's Wort
For example, medications, creams or food (this includes nut and soya bean oils)
(1 pint of beer is approximately two units and one small glass of wine is 1 unit)
For your safety, we will email you information about your contraceptive pill. It is important that you read this.