Contraceptive pill repeat prescription

Section

Address (House Name / Number, Street Name): *

Postcode: *

Are you currently taking the oral contraceptive pill, prescribed by a GP in the UK? *

Yes

No

This form is only for patients who are already taking the oral contraceptive pill and want a repeat prescription.

If you want to start taking the contraceptive pill, please make an appointment with your GP or find a local family planning clinic through the Family Planning Association website.

Is there any chance you could be pregnant, or have you had unprotected sex in the last 4 weeks (e.g. not using condoms when you have missed a pill)? *

Yes

No

It may not be appropriate for you to continue taking the COC. Please do not submit this form but contact your GP or Family Planning Clinic to discuss instead.

Was your blood pressure below 140/90 within the last 6 months? *

Yes

No

Raised blood pressure can make it unsafe for you to take the oral contraceptive pill. Please do not submit this form but contact your GP or Family Planning Clinic to discuss instead.

Blood Pressure

Please enter your blood pressure reading:

Systolic ‘Higher’:

Diastolic ‘Lower’:

Heart Rate:

Smoking Status

Which of the following applies to you?

I am a smoker.

I have never smoked.

I stopped smoking more than a year ago.

I stopped smoking less than a year ago.

The combined oral contraceptive pill is not suitable for all smokers. For instance, women over 35 who smoke or have stopped smoking within the last year should not take the combined oral contraceptive pill because it increases the risk of complications.

Please continue to submit this form. Your GP will let you know if they can issue a prescription.

Please read our patient information leaflet on the combined oral contraceptive pill for more information.

What is your weight in kilograms (within the last week)? *

What was the date of your last period? *

If you are not sure if you are taking a combined oral contraceptive (COC) pill or a progesterone only pill, please check your packet and then select the correct option.

COC Pill

The COC pill contains two ingredients, oestrogen and progesterone. Common brands include Microgynon, Rigevidon, Marvelon, Mercilon, Cilest, Ovranette, Yasmin, Femodene, Loestrin, Brevinor, Norimin.

Most COCs are taken for 3 weeks out of 4, with a 1 week gap. You will have been advised that you do not need to use another method of contraception as long as you have not missed a pill by more than 1 day.

Progesterone Pill

The progesterone only pill is taken at the same time every day, without a week off. Common brands include Cerazette, Micronor, Norgeston, Noriday, Cerelle.

You will have been advised that you need to use another method of contraception if you miss a pill by more than 3 hours (or more than 12 hours if you are taking a desogesterol pill).

Are you currently taking: *

The combined oral contraceptive pill (oestrogen and progesterone)?

The progesterone only pill (sometimes called the ‘mini pill’)?

Progesterone Pill

Do any of the following apply to you?

You have been diagnosed with heart disease or a stroke.

You have been diagnosed with severe liver problems, such as cirrhosis of cancer of the liver.

You have been diagnosed with breast cancer.

You have had abnormal vaginal bleeding since your last prescription was issued.

None of the above.

It may not be appropriate for you to continue taking Progesterone. Please do not submit this form but contact your GP or Family Planning Clinic to discuss instead.

Combined Oral Contraceptive Pill (Oestrogen and Progesterone)

It may not be appropriate for you to continue taking the COC pill. Please do not submit this form but contact your GP or Family Planning Clinic to discuss instead.

Suffering from migraines can increase your risk of serious complications from the COC. If your doctor knows about your migraines and has advised you that it is safe to take the COC, please submit this form.

However, if your migraines become worse or you develop symptoms of aura along with your headach (e.g. flashing lights before the headache) please contact your GP to advise them of this.

Please tell us the name of your oral contraceptive pill: *

Please tell us the name of the pharmacy you would like your prescription delivered to (or put ‘practice’ if you would like to collect the prescription from the practice):

Please tell us any time in the next 2 working days when you are not available for the practice to contact you. We will try to avoid these times, but please be aware that this may not be possible so do try to be available:

This service is intended for electronic communication between you and your Practice. The information may be read by any member of the Practice team and responded to by the most appropriate member of the team. Your Practice will endeavour to respond within the timeframe set for this form but will not be able to respond to urgent requests through this service.

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Section

Blood Pressure

Smoking Status

Progesterone Pill

Combined Oral Contraceptive Pill (Oestrogen and Progesterone)