The following questions help us to decide if you can safely continue with your current contraception. If you need emergency contraception please contact your local pharmacy you can not request emergency contraception by submitting this request
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If you have missed a pill(s) or think you might be pregnant you must contact the surgery on (01446) 772383 otherwise please completed the rest of the form
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Do you have any specific questions or concerns about your contraception?
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Why are you taking contraception?
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Which type of contraceptive pill do you take
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What is the name of your current contraceptive pill?
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Have you used emergency contraception in the last year?
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Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? *
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Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? *
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Do you have any abnormal vaginal discharge?
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Have you had a normal smear test in the last 3 years
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Can you tell us a recent blood pressure you have done at home, at the pharmacy or in the surgery waiting room, this is needed before an prolonged prescription is given?
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Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?
Have you been diagnosed with or experienced any of the following conditions in the past 12 months?
Are you currently taking any of the following medications?
Have you forgotten to take your pill on more than one occasion per month?
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Would you like to discuss what to do in the event of a missed pill?
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Would you like to discuss alternatives to taking a daily pill, for example, longer acting reversible contraception options (coil, injection or implant)?
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Is there anything else you would like to tell us that we have not already asked?
Which is your preferred pharmacy?
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This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
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