• Contraception request

    Consent

  • Staff - STOP! The fields in this form all have unique underlying field names that are tied to values the pill check system is expecting. Contact Michael for more information (michael.penston@nhs.net / 07709 649133).

  • In order to use this system, you must:

    • accept that requests take TWO WORKING DAYS to process
    • accept that we reserve the right to reject any request on reasonable clinical grounds where a doctor declines to provide the medication without review
    • accept your data being submitted using Jotform, which is a GDPR-compliant, EU-based, secure form software provider
    • provide information that is correct and up-to-date to the best of your knowledge
  • Do you:*

  • Your details

  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Previous prescriptions

  • Have we prescribed this product for you previously?*

  • Please continue to fill in the rest of this form. We might need to contact you if we need more information before we prescribe.

  • How long have you used this contraceptive for?*

  • Satisfaction with contraception

  • Are you happy with your current contraception or have you had any problems?*

  • Highlighting changes to medical history

  • Have there been any changes to your medical history since you were last ordered contraception?*

  • What are you ordering?

  • Which form of contraception are you ordering?*

  • Please note, you cannot order coils (IUD), Mirena, Kylena, Jaydess etc (IUS), condoms or sterilisations via this form.

     

  • Combined contraception

  • Which combined oral contraception?(i.e. oestrogen plus what other agent?)*

  • Combined contraception - medical history

  • Some conditions mean you cannot take combined contraception. Please tell us if you have ever suffered from or been diagnosed with any of the following conditions:

  • Organ transplant*
  • Raised blood pressure*
  • Ischaemic heart disease (e.g. a heart attack)*
  • Vascular disease (e.g. PVD, claudication)*
  • A stroke (CVA) or transient ischaemic attack (TIA)*
  • A blood clot (e.g. DVT, VTE)*
  • Factor V Leiden, prothrombin, protein S, protein C or antithrombin mutations*
  • Valvular heart disease*
  • Congenital heart disease*
  • Cardiomyopathy*
  • An arrhythmyia (e.g. AF, long QT)*
  • Idiopathic intracranial hypertension*
  • Epilepsy*
  • Breast cancer*
  • Gallbladder disease*
  • Hepatitis*
  • Liver disease*
  • SLE or antiphospholipid antibodies*
  • Chronic kidney disease*
  • Sickle cell disease*
  • Do you use a wheelchair?*
  • Has anyone in your family had a blood clot in the leg/lungs?*
  • Has any family member been diagnosed with BRCA 1 or 2 mutations?*
  • Have you ever had a migraine?*
  • Did your migraines start before or after you first took contraception?*
  • Have you had aura before or during any migraine? (eg flashing lights, sparkles, stars, blind or coloured spots, tunnel vision, zigzag lines, taste change, speech change, etc)*

  • Progestogen-only contraception

  • Which progestogen-only oral contraception?*

  • Progestogen-only oral contraception- medical history

  • Some conditions can interfere with contraception. Please tell us if you have ever suffered from or been diagnosed with any of the following conditions:

  • Ischaemic heart disease (e.g. a heart attack)*
  • A stroke (CVA) or transient ischaemic attack (TIA)*
  • Unexplained vaginal bleeding*
  • Breast cancer*
  • Liver disease*
  • Migraine*
  • Chronic kidney disease*
  • Sickle cell disease*
  • Do you use a wheelchair?*

  • Progestogen injection - medical history

  • Some conditions can interfere with contraception. Please tell us if you have ever suffered from or been diagnosed with any of the following conditions:

  • Diabetes*
  • Raised blood pressure*
  • Raised cholesterol or triglycerides*
  • Body mass index >30*
  • Ischaemic heart disease (e.g. a heart attack)*
  • Vascular disease (e.g. PVD, claudication, stroke, TIA)*
  • A transient ischaemic attack (TIA) or stroke (CVA)*
  • Unexplained vaginal bleeding*
  • Breast cancer*
  • Liver disease*
  • Chronic kidney disease*
  • Sickle cell disease*
  • Do you use a wheelchair?*

  • Other medication

  • You must tell us if you are taking any of the following drugs, because they can interfere with contraception:

    • aprepitant
    • bosentan
    • carbamazepine
    • efavirenz
    • eslicarbazepine
    • fosphenytoin
    • lumacaftor
    • modafinil
    • mounjaro
    • nevirapine
    • oxcarbazepine
    • phenobarbital
    • phenytoin
    • primidone
    • rifabutin
    • rifampicin
    • ritonavir
    • rufinamide
    • St John's wort
    • tirzepatide
    • topiramate
  • Do you take any of the above medications?*

  • Observations

  • We will only be able to provide your contraception, once we have this information.

    You can use the machine in reception to take these readings.

  • Please enter your weight (kgs) & height (cms)*

  • Smoking history

  • What is your smoking status?*
  • Would you like help to quit smoking?
  • Do you use vapes?*

  • Sexual health

  • Have you had any new partners since your last sexual health check?*

  • You need to check your status by ordering a self-test kit from the Sexual Health team. You can order online at letstalkaboutit.nhs.uk. This will be posted to you in plain packaging for you to discretely complete at home.

    If you have any symptoms of a sexual infection, you should call the Sexual Health team on 0300 300 2016 to request an appointment.

    Information on sexual health can be read at the NHS website

  • Prescription destination

  • We will send your prescription electronically to your pharmacy. Please tell us which pharmacy you wish to collect from:*

  • Declaration

  • Should be Empty: