Oral Contraceptive Pill Check

If you would like to request a repeat prescription of the contraceptive pill you are currently taking and you are due a review of this medicine then please fill out the form below.

When you are taking the oral contraceptive pill you need to have a review (including blood pressure and weight) at least every 12 months. You may be due a review sooner if you have recently started or changed your contraceptive pill.

The information will be sent to the practice team and your request will be processed within 48 hours.

Your First Names

Your Last Name

Your Date of Birth

Your Phone Number

Your Email

What is the name of your contraceptive pill?

Please confirm that you have no new concerns about this pill (if you have new concerns/questions please book an appointment to discuss further):

I confirm that I have no new concerns about this pill

Have you started any new medication since we last issued you a prescription for the pill?

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

Do you smoke?

Do you suffer from migraines with aura (aura is when there are specific warning signs just before the migraine begins, for example visual disturbance)?

Have you ever experienced any bleeding after sex?

Please be aware that certain over the counter medicines and herbal remedies such as St Johns wort can reduce the efficiency of the pill. Please check with a health care professional if you have any concerns

Have you ever had a blood clot?

Have any of your immediate family ever had a blood clot?

Have you ever had breast cancer?

Have any of your immediate family ever had breast cancer?

Information about what to do if you miss a pill can be found on the Family Planning Association website.

I confirm that I understand what to do if I miss a pill

If you experience:

*A sudden sharp pain in your chest, breathlessness or coughing up blood

*Painful swelling in your legs

*Weakness, numbness or bad “pins and needles“ in an arm or leg

*Unusual headaches or migraines that are worse than usual

*Sudden problems with your speech or eyesight

Seek medical advice immediately.

If you develop any new conditions, tell your clinician so that they can check its safe for you to take the pill.

If you go into hospital for an operation or have an accident which affects the movement of your legs or mobility, tell the doctor you are taking the combined pill. You may need to stop taking the pill or need other treatment to reduce the risk of developing thrombosis (blood clots). There are other contraceptive methods you can use instead.

Be breast aware, visit www.nhs.uk/how-should-i-check-my-breasts for further advice.

It is important we check your blood pressure and weight while you are taking the pill.

Please take the measurements below at the practice reception, in your local pharmacy or at home.

Height (in cm)

Weight (in kg)

Blood Pressure

Systolic (Top Number):

Diastolic (Bottom Number):

If you would like to read more about this and other contraceptive options please visit the Family Planning Association website.

If at any time you have concerns about your medication then please an appointment with a health care professional, this can be the clinical pharmacist, nurse or GP.

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

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Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Little Harwood Health Centre • Plane Tree Road, Little Harwood, Lancashire, BB1 6PH.

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