Contraceptive Pill Review

This form is to be used for the following reasons:

  • If you would like to start a new contraceptive (will also need to complete an e-consult)
  • If you want a repeat of your current contraceptive
  • If you wish to switch contraceptives (will also need to complete an e-consult)
  • If you have been advised by a clinician to complete this form

Once this form is completed it is passed to a clinician to review. Once contraceptives are issued you will receive a text to collect your prescription at your nominated pharmacy. Please ensure your nominated pharmacy is up to date – please call reception to do so.

You should get a response within a week, if you do not hear anything please call reception.

Resources:

Contraceptive Pill Review

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Contraception Pill Review

Please use date format DD/MM/YYYY
Do you need a repeat of your current contraception?

Please check your blood pressure (if you do not own an at home blood pressure monitor/scales, please call reception to book a blood pressure appointment with the Healthcare Practitioner). A recent reading (within the past year) will suffice:

/
Smoking status:
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Do you have any irregular bleeding? This includes bleeding or spotting in between your periods or after sexual intercourse
Do you have a history of abnormal smear tests?
Do you perform regular breast examinations on yourself?
For more information please see this leaflet about being breast aware.
Do you currently have or have you ever previously suffered from diabetes, DVT (blood clots), breast cancer, cardiovascular disease, liver disease or migraines?
Does anyone in your family have a history of cardiovascular disease, stroke or breast cancer?
Are you aware of the risks associated with oral contraception?
*
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