Contraceptive Pill Request Form

If you would like to request further prescriptions of the contraceptive pill please complete this form.

Last Updated: 21/02/2023

Your Details

Name *

Date of Birth *

Contact Number *

Email Address *

Contraceptive Pill Review

The following questions help us to decide if you can safely continue with your current contraception. If you need emergency contraception please contact your local pharmacy you can not request emergency contraception by submitting this request *

Okay, I understand

If you have missed a pill(s) or think you might be pregnant you must contact the surgery on (01446) 772383 otherwise please completed the rest of the form *

Okay, I understand

Do you have any specific questions or concerns about your contraception? *

Why are you taking contraception? *

Birth control

Period control

Other

Which type of contraceptive pill do you take *

Combined hormonal contraceptive pill (e.g. Cilest, Loestrin, Microgynon, Rigevidon, Yasmin)

Progesterone-only/mini pill (e.g. Cerazette, Cerelle, Noriday)

Don't know

What is the name of your current contraceptive pill? *

Have you used emergency contraception in the last year? *

Yes No

Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months? * *

Yes No

Do you suffer from migraines with aura, or a headache associated with weakness or numbness on one side of your face or body, or difficulty with speech? * *

Yes No

Do you have any abnormal vaginal discharge? *

Yes No

Have you had a normal smear test in the last 3 years *

Yes

I don't know

I've not had a smear test yet (smear tests start after 25th birthday)

Current weight? *

Can you tell us a recent blood pressure you have done at home, at the pharmacy or in the surgery waiting room, this is needed before an prolonged prescription is given? *

Have you, or any of your immediate family (mum, dad, brothers or sisters) been diagnosed with any of the following conditions within the past 12 months?

Deep vein thrombosis (a blood clot in the veins of the leg)

Pulmonary embolism (a blood clot in the lungs)

Stroke or cerebro-vascular disease

Heart disease

Breast cancer under the age of 50

Have you been diagnosed with or experienced any of the following conditions in the past 12 months?

Are you currently taking any of the following medications?

Anti-epileptic medication

Rifampacin

St Johns Wort

Roaccutane (isotretinoin)

Have you forgotten to take your pill on more than one occasion per month? *

Yes No

Would you like to discuss what to do in the event of a missed pill? *

Yes No

Would you like to discuss alternatives to taking a daily pill, for example, longer acting reversible contraception options (coil, injection or implant)? *

Yes No

Smoking Status *

Smoker - more than 15 per day

Smoker - less than 15 per day

Ex-Smoker

Non-Smoker

Is there anything else you would like to tell us that we have not already asked?

Which is your preferred pharmacy? *

Lloyds (Cowbridge)

Sylvia Williams (Cowbridge)

Boots (Llantwit Major)

Well (Llantwit Major)

St Athan

Anne Williams (Pontyclun)

Pontyclun

Other

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Contacting you

Do you agree that we can contact you via SMS and or email in relation to your contraception pill request? We may also contact you from time to time with health advice, important practice information and or appointment reminders *

Yes No

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Contraceptive Pill Request Form

Further Information