Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

If you are human, leave this field blank.

Full Name: *

Phone Number: *

If you do not have a phone number, please put N/A.

Please specify the ethnic group the patient belongs to: *

Please specify: *

Do you regularly check your breasts?

Yes

Please ask reception for our information regarding the importance of regular breast self-examination.

Do you suffer from severe headaches or migraines?

Yes - But the Doctor is unaware

Yes - But the Doctor is aware

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Are you experiencing any irregular bleeding?

Yes

Please book an appointment to see the practice nurse

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

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