Contraceptive Injection Review

Full Name *

Date of Birth *

Contact Phone Number *

Email Address *

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.

Contraceptive Pill Review

Weight (kg) *

Height (cm) *

Blood pressure (mmHg) from a home monitor or via a local pharmacy that offers BP check *

Smoking status *

Never smoked

Ex-smoker

Current smoker

If ex-smoker, please advise on date stopped:

If current smoker, please advise how many cigarettes per day you smoke:

Alcohol intake - do you drink alcohol? *

Yes No

If yes, how many units per week on average do you drink? 1 unit = half a pint of beer, a small glass or wine or one 25ml measure of spirit.

What happens next?

Once returned to the practice, a clinician will review your answers and issue your prescrption as appropriate.

If there are any queries or we have reason to speak with you before your prescription can be issued, you will be contact to arrange an appointment.

If there are no queries and we do not need to speak with you, your prescription will be issued for a year's supply* and sent to your preferred pharmacy. Please allow 7 working days before collection.

We will ask you to complete this review yearly, prior to your prescription being reauthorised, to ensure that it remains appropriate for you to continue taking.

* The practice is currently in the process of moving annual reviews to birth month, so a prescription may be issued for a shorter duration to take you into your next birth month to align annual review with birth month going forward.

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Contraceptive Injection Review

Further Information