Contraception request
In order to make sure that is safe for you to take the PILL/patch/ring the surgery requires update our records with your latest information

** We require your latest weight and Blood pressure (BP) every year. Please submit online if you have this to avoid being advised to collect your prescription and perform the BP at reception
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Your Details
Please include your latest personal details so that we can contact you if necessary
Your Full Name *
Your Date of Birth *
Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980
MM
/
DD
/
YYYY
Your MOBILE number *
If we need to contact you to clarify your answers
Your EMAIL address *
If we need to contact you to clarify your answers
CONTRACEPTIVE PILL or patch/ring
Examples of Combined pill (oestrogren + progesterone)
Microgynon, Rigevidon, Levest, Ovranette, Cilest, Zeletta, Loestrin 20/30, Mercilon, Gedarel 20, Marvelon, Gedarel 30, Femodene, Katya, Millinette, Yasmin, Lucette, Yiznell , Evra patch, Nuvaring
Examples of Mini Pill (Progesterone only)
Desogestrel, Cerazette, Cerelle, Femulen, Norgeston, Micronor, Noriday, Microval
What type is your contraceptive pill? *
If you are still not sure please read the box/packet and check. If it contains oestrogen (ethinyloestradiol) it is a combined pill
What is the full name of the PILL you would like to request? *
Please enter full name of the pill you are taking e.g. Microgynon, Mavelon, Mercilon, Cilest, Cilique, Rigevidon, logynon, Yasmin, Dretine, Qlaira, Femodene, Femodette. Includes Nuvaring & Evra patch
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