The Combined Pill Review Form

Email *

Confirm Email *

Date of Birth *

Please use format day/month/year e.g. 12/05/1979

Combined Pill Review

Are you happy with your current Pill? *YesNo

Your blood pressure *

Do you smoke? *YesNo

Have you ever had a blood clot, heart disease, stroke, cancer, migraine or major illness? *YesNo

Do you understand the risks and benefits of your current contraceptive? *YesNo

Have you read about or do you already take the pill continuously? *YesNo

Have you considered the coil or implant? *YesNo

Best number to call you on *

One of our clinicians will contact you on this number in the next couple of weeks.

Any comments you would like to add?

Privacy Policy

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.

Your consent *I consent to the practice collecting and storing my data from this form.