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Contraceptive pill & patch review form

This form is for patients aged 16-49 years who are currently using the contraceptive pill or patch for their regular contraception (ie not emergency contraception/morning after pill), are happy with their current contraception and want to continue with it.

You’ll need a recent blood pressure reading and your weight to complete this form – you can use a BP home monitoring machine, and scales you have at home. A BP monitor is also available in our main waiting room for patients who aren’t able to get a BP home monitoring machine, along with weighing scales.

A nurse will review your form and – if safe to do so – will re-prescribe your contraception. We’ll send you a text to let you know. Your prescription will then be available for collection at your nominated pharmacy (please allow around 7 working days after submitting this form) or from Reception (please allow 5 working days after submitting the form).

You’ll then need to complete this review form every time you’d like us to re-prescribe your contraception (usually every 12 months).

If after reviewing your form we need to have a further discussion with you before re-prescribing your pill, we’ll text you to ask you to book an appointment with one of our specialist nurses.

Contraception review
Please use format day/month/year e.g. 12/05/1979
Are you aged 16-49 years?
If you’re not aged 16-49 years please don’t fill in this form. Please call us on 0300 790 6266 after 10am Monday-Friday to book an appointment with one of our specialist nurses to discuss your contraception.
Are you CURRENTLY taking the pill or patch for your regular contraception (ie you’re not using it for emergency contraception/morning-after pill, and you’ve not had a break from contraception for any reason)?
If you’re not currently using the contraceptive pill or patch (or have had a break in contraception) then please don’t fill in this form. Please call us on 0300 790 6266 after 10am Monday-Friday (or come to the front desk) to book an appointment with one of our specialist nurses to discuss your contraception.
Are you seeking emergency contraception (eg the morning-after pill)?

If you think you need emergency contraception (eg the morning-after pill) then please don’t fill in this form.

If you think you might need emergency contraception because you’ve had unprotected sex or your contraceptive method has let you down, you can phone NHS Lothian’s Chalmers Sexual Health Centre on 0131 536 1070 Monday-Friday, 9am-3pm.

Or, you can call the Practice on 0300 790 6266 after 10am Monday-Friday (or come to the front desk) to book an appointment with one of our specialist nurses to discuss emergency contraception.

Are you happy with your current contraception and want to request it again?

If you’re not happy with your current contraception and don’t want to continue with it, please don’t fill in this form.

To book an appointment to discuss the full range of contraception options open to you, please call NHS Lothian’s Chalmers Sexual Health Centre on 0131 536 1070.

We offer a small number of contraception options at the Practice – the pill, patch, injection and implant (Nexplanon only). If you want to discuss these options, you can call us on 0300 790 6266 after 10am Monday-Friday (or come to the front desk) to book an appointment with one of our specialist nurses.

Your blood pressure

Enter a recent blood pressure reading

This can be done with your own BP monitor you have at home. There’s also BP monitor available for patients to use in our main waiting room. A blood pressure reading is usually written like this:

110/70

110 is your systolic blood pressure and 70 is your diastolic blood pressure. Please enter them in the right box below so we can calculate if you have a healthy blood pressure.

Please book a blood pressure appointment within a week with one of the specialist nurses at the Practice.

Please call us on 0300 790 6266 after 10am Monday-Friday or come to the front desk to book an appointment.

Your systolic blood pressure is too high for us to re-prescribe your contraception, please don’t continue filling in this form.

Please contact us urgently to book a blood pressure appointment today or the next working day with one of the specialist nurses at the Practice.

Please call us on 0300 790 6266 after 10am Monday-Friday or come to the front desk to book the appointment.

Your systolic blood pressure is too high for us to re-prescribe your contraception, please don’t continue filling in this form.

Please book a blood pressure appointment within a week with one of the specialist nurses at the Practice.

Please call us on 0300 790 6266 after 10am Monday-Friday or come to the front desk to book an appointment.

Your diastolic blood pressure is too high for us to re-prescribe your contraception, please don’t continue filling in this form.

Please contact us urgently to book a blood pressure appointment today or the next working day with one of the specialist nurses at the Practice.

Please call us on 0300 790 6266 after 10am Monday-Friday or come to the front desk to book the appointment.

Your diastolic blood pressure is too high for us to re-prescribe your contraception, please don’t continue filling in this form.

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Your other health information

How would you describe your smoking status?
Do you use vapes / electronic smoking devices?
Have you missed any pills in the last 12 months?
0 of 200 max characters
Do you have migraines with visual disturbance or aura?
Do you have any concerns regarding your bleeding pattern?
Have you noticed any side effects?
Has anything changed with your health in the last 12 months?
Have you had a heart attack, stroke or diabetes diagnosis since your last contraception review?
Have you or anyone in your family had a blood clot – eg a DVT (deep vein thrombosis) or pulmonary embolism – since your last contraception review?
Has anyone in your family been diagnosed with breast or cervical cancer since your last contraception review?
Have you been diagnosed with any form of cancer since your last contraception review?
Do you have any allergies?
Do you have a Nexplanon (contraceptive implant) currently?

Your details

What will happen next?

We’ll review your contraception review form within five working days and will text you to let you know the outcome.

We’ll use the mobile number on your patient record. If we don’t have a mobile number on record for you (or you’ve recently changed mobile number) please fill in our change of contact details form.

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.

Privacy Policy

Your feedback

Did you find this online form a better way of arranging review and re-order of your contraception rather than calling the Practice to book a review appointment?