Family planning online form/repeat contraceptive pill

First Name

Last Name

Date of birth

Mobile number

If you are aged 16 to 18 years old, are you in full-time education?

Yes

No

What contraceptive would you like to start?

What contraceptive medication are you taking? Eg. Combined Pills - Microgynon/Rigevidon/Levest/Ovranette, Cilest/Zeletta, Loestrin 20/30, Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell, Evra patch, Nuvaring Progestogen-Only Pills-Desogestrel/Cerazette/Cerelle, Femulen, Norgeston, Micronor/Noriday, Microval

Any problems with using your contraception or side-effects from it? Eg. Increased weight, nausea, headache/migraine, abdominal pain, etc

Yes

No

If yes, please specify...

Any new/unusual bleeding? Eg. Between periods/during or after intercourse

Yes

No

Any changes in your Personal or Family History (mother or sibling) including Breast cancer/ Thrombosis (blood clots in legs veins or lungs)? You may be able to continue the contraception, but we would like to discuss this with you

Yes

No

Have you ever suffered from migraines?

Yes

No

If so when was your last one?

Where did you get your contraception from last time

Oak Tree
Family Planning Clinic
Other (please give details)

Do you smoke? If so, how many per day?

What is your height? (cm)

What is your weight? (kg) Recorded within past week

Blood Pressure Reading (Recorded within the past week). Please attend the surgery & use the POD if you don't have a machine at home.

Any allergies drug or non (please list all)

For patients who have a coil or implant in place and would like it taken out/another one put in please give us details here:

When we have received this form we will contact you by text to give you an appointment to discuss your request. Would you prefer this appointment to be

On the phone
Face to Face
I don't mind

If we are satisfied we have all the information to safely prescribe your contraception we may be able to let you know by text and send the prescription straight to the pharmacy, would you be happy with this?

Yes

No

Nominated Pharmacy

Message for GP (if required)

Oak Tree Surgery

Family planning online form/repeat contraceptive pill

For those wanting to start a new contraceptive

For those wanting a repeat of their contraception

For patients requesting a new contraception or those on the combined pill/patch/ring – you must complete the following before we can offer a prescription