Ladywell Medical Centre West

NHS Scotland

Combined Contraceptive Review Form

Combined Contraceptive Review Form
Please use format day/month/year e.g. 12/05/1979
Are you happy with your current contraceptive pill? *
Since last review, have you had a blood clot, heart disease, stroke, cancer, new migraine or major illness? *
Have you had any unexpected bleeding or change in bleeding pattern? *

 

Please read The Combined Pill Guide before answering the following questions.

Do you understand the risks and disadvantages associated with your current contraceptive? *
Do you know the benefits of your current contraceptive? *
Do you know what to do if a pill is missed, if you have vomiting or diarrhoea, or if you require surgery? *
Do you take your pill as advised by your doctor and consistently? *

 

Please visit Contraception Choices to investigate the coil and implant options.

Have you considered the coil or implant? *
Are you able to provide your blood pressure reading (eg.: home monitor, pharmacy)? *
e.g. 120/70

A prescription will be sent to your preferred pharmacy within 5 days.

Please continue to complete this form and phone the surgery to make an appointment with a nurse. In the meantime, we will send a prescription for 3 months of your pill to your pharmacy. This option can only be used ONCE.

e.g. 65 kg
e.g. 165 cm
Do you smoke? *
Do you consent to be contacted via text message? *

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.

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Ladywell Medical Centre West

10 Ladywell Road
Edinburgh
EH12 7TB

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