Contraceptive Pill Review Form


IMPORTANT

Your prescription will be sent to your chosen nominated pharmacy. If you have not chosen a nominated pharmacy please complete a 'nominate a pharmacy' form via our online forms page before proceeding with this form. 


PLEASE NOTE: 

To process this form the practice will require an up-to-date blood pressure reading within the last 6 months. Please DO NOT continue with this form if you do not have an up-to-date BP. 


In order to provide the contraceptive pill safely we need to ask you a number of questions. We would be grateful if you could complete this form when you submit your next repeat prescription request. If you are having any problems with your medication or would like to consider an alternative contraception option, please speak to one of our Practice Nurses/Pharmacist who will be able to advise you or refer you to the appropriate service.


DID YOU KNOW: 

There are several local pharmacies which are also able to provide initiation and continuation of contraception including:

High Street Pharmacy
Available on a Monday

Anuerin Evans Pharmacy
Available on a Wednesday and Thursday

Brockway Pharmacy
Available Monday to Friday

 

Last Updated: 02/10/2023

  • Your Details

  • Contraceptive Pill Review

    Have you had your blood pressure checked in the surgery in the last 12 months?
    Are you a smoker?
    Would you like help giving up? (optional)
    Do you take any over the counter medicines (Vitamins, supplements etc)
    Are you aware how the pill works?
    Do you know what to do if you miss a pill?
    Did you know that the contraceptive pill may not work if you have diarrhoea or vomiting or are on antibiotics?
    Are you aware that the contraceptive pill does NOT protect you from sexually transmitted infections, so you will need a condom as well to protect yourself
    Do you understand that you should tell a healthcare professional that you are on the pill if you need to have an operation or have a prolonged period of immobilisation e.g. leg in plaster?
    Are you aware of the alterative such as long acting reversible contraception? Such as Implants, injections and intra-uterine devices (The Coil)
    Do you have any blood clotting illnesses or abnormalities?
    Have you ever had any clots in the Arms, Legs or Lungs?
    Do you understand the symptoms of blood clotting can include shortness of breath, sharp chest pain, coughing up blood, calf pain and swelling?
    Do you know the risk of a clot increases with the combined pill if you travel for extended periods? e.g. long-haul-flight
    Do you have parents or siblings who have had any clots in their Arms, Legs or Lungs under the age of 45?
    Do you have any parents or siblings who have had heart disease or strokes under the age of 45?
    Do you suffer from migraines?
    Do you have diabetes?
    Do you suffer from any of the following?
    Have you suffered from any irregular vaginal bleeding, bleeding in between periods or bleeding after sex in the last 12 months?
    Are you breastfeeding?
    Do you check your breasts regularly?
    Do you have any breast cancer history under the age of 50?
    If you are over 25 is your Cervical Screening test (Smear Test) up to date?

  • Consent

    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 Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.
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