Home
How Do I?
About
Services
Contact Us

Medication
Review Form

Progesterone Only Pill Review

Make an Appointment

03300 536456

Request an Appointment Online

Progesterone Only Pill Review Form

Required fields are marked with an asterisk (*).

Please note:

If you are aged 55+, please book a face-to-face appointment
Age 50+ and would like to discuss how long you have taken your pill, please make a face-to-face appointment

If you are looking to start a family, we would encourage you to start taking folic acid when you stop your pill.

Your Contact Details

Name

First

Last

Date of Birth*

Email address*

Phone Number*

Which pharmacy would you like your prescription sent to?*

HEALTH CHECK

Height*

Weight*

Do you smoke?*

Yes

No – Never smoked

No – Ex smoker

Is your cervical smear up to date?*

Yes

Unsure

PILL-RELATED QUESTIONS

Name of current pill*

Are you happy to continue on your current pill?*

Yes

Have you experienced any side effects?

Are you aware of late/missed rules?*

Yes

Are you aware that if you vomit within 2 hours of taking your pill, it may not be effective?*

Yes

Do you struggle to remember to take your pill?*

Yes

If you answered yes to the above, would you like an appointment to discuss other potential methods of contraception, such as implants, coils etc?*

Yes

Are you concerned about any abnormal bleeding (bleeding between periods or during/after sex)? *

Yes

Do you feel safe in your relationship?*

Yes

What length of prescription would you like? *

3 months

6 months

1 year

Privacy Consent – This form collects personal and medical information about you/ We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage submitted data.

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

Are you human?*