Form: Contraceptive Pill Review




In order to provide another prescription of your contraceptive pill we need to ask you a number of questions. 

  • This form is not to be used if you have not started the contraceptive pill already or have recently had a break from your usual pill. 
  • If you are having problems with your contraceptive pill or would like to switch to a different pill or other method of contraception, please do not use this form and book an appointment to see one of our nurses. 
  • This form is only to be used by women aged 16 years or older. 

Please fill out the following information: 

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Personal Details

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

Please double check you've entered the correct email address
May be used to identify you
Contraception Pill Review
ie: to manage periods, contraception only or both.

Your Recent Blood Pressure

If you do not supply a recent reading, we will not be able to issue a prescription. We now have a blood pressure monitor in the surgery if you don't have access to a machine at home.

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Please ask reception for our information regarding the importance of regular breast self-examination.

Please book an appointment to see the practice nurse

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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