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Prescriptions: Contraceptive Review "Pill Check" & Medication Review

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

You will need an up to date weight and blood pressure.

Information on various contraceptive can be found below:

Combined pill
Progesterone only pill
Contraceptive patch
Vaginal ring

It is advised where possible to consider long acting contraceptive options like the implant or coil. To find out more information or book your appointment for long acting contraception please click the link below:

Coil & Implant
Mood Questionnaire
Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations. 
Prescriptions: Contraceptive Review "Pill Check" & Medication Review
Medical history

Some medical conditions can mean hormonal contraception is not a safe option. Please answer the following questions below about your own health and family history.

This could be inbetween your periods if you have a regular cycle, or after sex
If you select yes please make a telephone appointment to discuss this with one of our clinical team.
e.g. 120/80 (Upper valve/Lower value). If you do not know your blood pressure then you will need to have your blood pressure checked by using a home BP monitor, attending a chemist or booking an appointment at the surgery before your prescription can be issued.
In Kg or Stones & lbs
Prescription details
This relates to all your medications if you are on more then just the oral contraceptive. Please state the medication and the side effect. E.g. Paracetamol: Constipation
If you are struggling with your mental health please contact the practice or if out of hours or in an emergency call the CRISIS team: 0300 200 0011 and select option 1.
Please note that if your mental health is currently significantly impact and you are concerned for your well-being you must contact the crisis team on 0300 200 0011 and select option 1 or 999.

Thank you for completing this form

If no write: NO. If yes, please state the name and dose of these medications.

It is important that you complete a cervical smear regularly.

under 25 up to 6 months before you turn 25

25 to 49 every 3 years

50 to 64 every 5 years

65 or older only if 1 of your last 3 tests was abnormal

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