Mini-Pill/Progesterone-only Contraceptive Pill Review

If you have been advised by the surgery to submit a Mini-Pill/Progesterone-only Contraceptive Pill Review please use this form.

Use this form ONLY if you are taking Cerelle (desogestrel), Noriday or Norgeston.

Should you have been asked to submit a Combined Contraceptive Pill/Patch Review please visit this page.

Mini-Pill/Progesterone-only Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Are you experiencing any irregular bleeding?

Please book an appointment to see the practice nurse

Has anyone in your family had breast cancer? *
Do you regularly check your breasts? *

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

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