Appointments – 01270 376666
Cancellation Line – 01270 376888

Contraceptive Pill

You can order a prescription of your contraception by completing this form, alternatively paper request forms are available from Reception.

You will need to take a current blood pressure reading. If you do not have access to a home blood pressure monitor, you can use our blood pressure machine which is located outside Room 12.

If you have any problems with your medication, or would like to consider alternative contraception options, you can speak to one of our Practice Nurses, who will be able to advise you or refer you to the Doctor as appropriate. More information about contraceptive choices are available here.

In order to provide the contraceptive pill safely we need to ask you a number of questions. Please answer the questions below to the best of your knowledge.

Contraceptive Pill Request Form

Name(Required)
DD dash MM dash YYYY
Home Address(Required)
1. Are you a smoker?(Required)
If you are interested in giving up, please contact your local pharmacy for smoking cessation information and support.
e.g GP, family planning clinic etc.
8. Are you aware of the alternatives, such as long-acting reversible contraception?(Required)
e.g depot injections, the coil, implant.
9. Do you find it difficult remembering to take your pill?(Required)
10. Is there any change in your medical history since your last pill check?(Required)
11. Any recent surgery?(Required)
12. Do you suffer from migraines?(Required)
13. Do you have epilepsy and on medication for it?(Required)
14. Have you or a close family member been diagnosed with breast cancer?(Required)
15. Have you or any family member suffered from blood clots in the leg or lungs?(Required)
e.g DVT or Pulmonary Embolism
16. Have you ever had a vascular disease, heart problems or heart attack?(Required)
17. Have you ever had a stroke or a mini stroke (TIA)?(Required)
18. Do you have any liver conditions, such as liver cirrhosis, liver cancer or liver tumour?(Required)

If you have answered 'YES' to any question(s) from 9 to 18, please book a telephone consultation with the nurse to discuss your repeat prescription.

Informed Consent(Required)
Consent(Required)
DD slash MM slash YYYY

Thank you for completing this form.