Contraceptive Pill Review

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

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.

Contraception Review

Please answer the questions below leaving any blank that are not relevant.
Please put "not known" if you do not know the date.

iCash - Contraception and sexual health advice:

Further contraceptive advice:

Please give as much information as possible in the box above.

Lifestyle & Health

For advice on quitting smoking, please visit:

Please select all that apply.
Please submit by giving us your most current reading. You can get an up-to-date blood pressure reading by visiting your local pharmacy, using a home blood pressure monitor or by visiting the surgery.

Please note that the details you give will be used to update your medical records.