Contraceptive Pill Review

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

Please allow at least 3 working days for us to process your request. If you don’t have enough medication to last you 3 days, please fill in the form but also call us to organise for an urgent prescription.

Contraceptive Pill Review

Contraceptive Pill Review

If you do not agree with the below statement(s), please book a telephone appointment to discuss this with the doctor. Your pill prescription cannot be issued until this appointment has taken place.

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If you were started on a pill at a different surgery, please complete the form, but we may ask you to book a routine telephone appointment to discuss your options.

If you are interested in having a Coil or Implant, please look at the FPA website and visit our Accessing Long Acting Reversible Contraception page.

These methods have a lower failure rate than the contraceptive pills and are available at the Brockwell Park Surgery as well as local family planning clinics.

Please use date format: DD/MM/YYYY
Are you taking the: *

Combined Pill

Unit of measurement: *
Unit of measurement: *

Current Blood Pressure

Your pill prescription cannot be issued without an up to date blood pressure reading.

If you need to use our blood pressure machine, please visit the surgery reception.

Smoking

Smoking status: *
Do you vape? *
Please select all that apply:

Any new medical diagnosis since the last pill review? *
Please see NHS: Combined Pill for relevant conditions.
Have you or any of your immediate blood relatives (parents, siblings, children) had breast cancer or been diagnosed with a BRCA1/BRCA2 mutation? *
Have you or any of your immediate blood relatives (parents, siblings, children) had a blood clot in their veins, or had three or more miscarriages? *
Do you suffer from migraines (headaches with additional features such as pulsating pain, nausea, sensitivity to light, noise or sound)?
For more information: Migraines
Have you ever had an aura (flashing lights gradually taking over your vision for roughly 20 minutes)? *
For more information: Migraine with aura

If you have stable longstanding migraines which you have discussed with us and you have never had an aura, you can safely continue your combined contraceptive.

If however you are having new onset migraines, more frequent migraines on the combined pill, or you have had an aura in the last 5 years, we need to think again. The combined pill puts you at higher risk of stroke in this setting. We would suggest that you switch to alternative contraception. Please book a telephone appointment as we will need to discuss this with you before issuing a prescription.

Progesterone Only Pill

Have you had any change in bleeding pattern since the last review? *
Any new medical diagnosis since the last pill review? *
Please see NHS: Progesterone Only Pill for relevant conditions.
Have you or any of your immediate blood relatives (parents, siblings, children) had breast cancer or been diagnosed with a BRCA1/BRCA2 mutation? *

Smoking

Smoking status: *
Do you vape? *
Please select all that apply:
*