Mini-Pill/Progesterone-only Contraceptive Pill Review

About You

Full Name: *

Phone Number:

Are you experiencing any irregular bleeding?

Yes

No

Please book an appointment to see the practice nurse

Has anyone in your family had breast cancer? *

Yes

No

Do you regularly check your breasts? *

Yes

No

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

Do you take any other medication that the surgery does not normally prescribe for you, including supplements and herbal medication? If so please give details:

Have you been given information about long acting reversible contraceptives (Implants, Coils or Injections)? Please see link for more information: www.nhs.uk/conditions/contraception *

Yes

No

*

I know that missing pills or having severe diarrhoea and vomiting may stop the pill from working effectively and I will need to follow advice in the patient leaflet or contact a doctor for advice

*

I confirm that the information provided is accurate to the best of my knowledge and that I am requesting this medication for my sole use and not on behalf of another person.

Do you want your prescription to be sent to a pharmacy or to collection a paper prescription from reception? *

Sent to pharmacy

Collect paper prescription

My chosen pharmacy is... *

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

Please provide any other information that is relevant or if there are any questions you have. For example, let us know if you are joining packs together and what advice you are following, or if you are requesting a prescription more than a month before you are due to run out please let us know why.

Tell us whether you accept cookies

Mini-Pill/Progesterone-only Contraceptive Pill Review

About You

Coronavirus advice from NHS111 online