Repeat Contraception Request Form

Please read the following questions carefully and answer each one as fully as possible. The form will be passed to a GP or Pharmacist so that your prescription can be issued. Sometimes a GP may contact you to discuss your answers. Otherwise you can expect your new prescription to be available within 7 days.

Repeat Contraception Request
Please use format day/month/year e.g. 12/05/1979
Would you like to discuss starting a longer acting method of contraception such as the coil, injection or implant with one of the GPs?
Have you had any irregular vaginal bleeding in between your periods?
Have you had any vaginal bleeding after sex?
Have you developed a new headache or migraine since your last review?
Have these ever been accompanied by warning symptoms prior to the headache, or associated symptoms, such as problems with your vision, numbness/tingling, or weakness?
Have there been any significant changes in your health since your last review?
(In particular – blood clots, heart disease, strokes and new diagnosis of cancer)
Do you have a family history of blood clots in a first degree relative (parent/sibling) under 45 years old?
Are you cervical smears up to date AND normal?
Have you noticed any NEW breast lumps or new changes with your breasts?
Do you currently smoke?

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.