Contraceptive Pill Request Form

Contraceptive Pill Request Form
Post Code
**If you have already run out or have less than two pills left, you should make an urgent appointment for a pill check instead of using this form**
(In stone & lbs OR kg)


Are you a smoker?
If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Side Effects

Are you experiencing any problems with your pill? *
Have you had any problems with forgetting to take your pill?
Have you had your blood pressure checked win the last 12 months?
If you are over 25, have you had a smear test in the last 3 years?
Have you been given information about implants &/or coils?
Please tick below to acknowledge that all information provided is accurate to the best of your knowledge: