Online Pill Check

If you take any of the oral contraceptive pills you will need an annual review (pill check) at least every twelve months before we can re-authorise your prescription.

This form will allow you to complete the pill check online. We have set up the online pill check with the aim of making it quicker and easier for you to renew your prescription if your pill is suiting you and you wish to continue it. If you are having any problems or concerns, or would like to discuss other forms of contraception, we would be more than happy to hear from you. Please book an appointment with one of our practice nurses.

To fill in this form you will need your current height, weight and blood pressure.

The pill check will be sent to the practice team and your request will usually be processed within 2 working days. If there are any issues we will contact you to discuss further.

Your Details

Full Name(Required)

Date of Birth(Required)

Email Address

Phone Number(Required)

Post Code(Required)

Height (cm)(Required)

Weight (kg)(Required)

Blood Pressure(Required)

Please enter your blood pressure in the XX/XX format.

Your Pill Check

What is the name of your contraceptive pill?(Required)

Do you require a prescription for your contraceptive pill?(Required)

Yes

Are you experiencing any problems with bleeding after sex or bleeding between periods(Required)

Yes

If you answered yes to this question then please arrange an appointment with one of our clinicians.

Are you on any other medication in addition to your pill?(Required)

Yes

If yes please state the medications below

Have you been diagnosed with any new health conditions since we last issued you a prescription?(Required)

Yes

If you answered yes to the above question then please state the health condition below and provide some more information.

Do you smoke?(Required)

Yes

If you answered yes to this question please answer the next 2 questions.

How many Cigarrettes do you smoke a day?

Would you like help/advice on how to stop smoking?

Yes

Do you drink alcohol?(Required)

Yes

If you answered yes to the above question then please also answer this question.

I drink OVER 14 units of alcohol per week

I drink UNDER 14 units of alcohol per week

Do you suffer from migraine headaches?(Required)

Yes

If yes please state whether you are on medication for this and what medication.

Aura is when there are specific warning signs just before the migraine begins, for example a change in your vision. It is vital you do not take combined oral contraception if you have migraine with aura, as this is known to increase your risk of stroke. If you are uncertain please contact the surgery to discuss(Required)

See The Migraine Trust Information for more clarification: https://migrainetrust.org/understand-migraine/types-of-migraine/migraine-with-aura/

I confirm that I have read this warning

Have you ever had a blood clot?(Required)

For example in your leg or in your lung, often referred to as a DVT or a PE.

Yes

If yes, please specify where.

Has a close family relative (parent or sibling) ever had a blood clot?(Required)

Yes

If yes, please specify where.

Have you ever had breast cancer?(Required)

Yes

Has a close family relative (parent or sibling) ever had breast cancer?(Required)

Yes

If yes, please specify relationship i.e Mother/Sister

Smear tests are an essential tool to prevent cervical cancer. They are offered to everyone with a cervix between the age of 25 and 64. The screening interval is every 3 years for those aged 25-49, and every 5 years for those aged 50-64. You will receive an invitation to book from the national screening service if you are due. Are you up to date with your cervical screening?(Required)

Yes

I am under the age of 25

If you have received an invitation or if you believe you are due for your smear test after reading the above information, please contact the surgery to arrange an appointment. For more information on cervical screenings please visit https://www.nhs.uk/conditions/cervical-screening/

Are you aware that there are more reliable, long-acting methods of contraception available?(Required)

You should be aware of other, more reliable long-acting methods of contraception, such as the Coil or the Implant. These methods of contraception can last 3-5 years and are more effective than any oral contraception. If you wish to discuss alternative contraception please arrange an appointment with our practice nurse.

I can confirm that I'm aware of alternative contraception methods that are on offer.

You should be aware that no contraceptive pill protects against sexually transmitted infections. Full sexual health screenings and self swabs are available locally.(Required)

I confirm that I have read and understood this statement.

For more information on local sexual health clinics please visit our website.

If you miss a pill, you may be at risk of an unplanned pregnancy. The rules for missed pills can differ depending on which pill you are taking. For more information this please visit https://www.nhs.uk/conditions/contraception/miss-progestogen-only-pill/ or https://www.nhs.uk/conditions/contraception/miss-combined-pill/.(Required)

I confirm that I have read and understood this statement.

I have read and understand what to do if I've missed a pill.

Your health and safety is important to us and we need to ensure that we have sufficient information to complete this review. If at any time you have concerns regarding your pill then please speak to one of our clinicians.(Required)

I confirm that the information I've provided is accurate to the best of my knowledge

Privacy Consent(Required)

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