Contraception request form

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:*

agree & consentdisagree

Previous prescriptions
Have we prescribed this product for you previously?*

YesNo
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?*

Less than 3months3 - 12 monthsMore than a year

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

Happy & problem-freeUnhappy or problems experienced
Please tell us about your problem(s):*

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

No, no changes to my healthYes, things have changed
Please tell us what is different from beforehand:*
e.g. I was seen by a neurosurgeon, diagnosed with FND & now take lamotrigine

What are you ordering?
Which form of contraception are you ordering?*

COMBINED OESTROGEN & PROGESTOGEN ORAL TABLETSPROGESTOGEN-ONLY ORAL TABLETSPATCH (Evra)VAGINAL RING (Nuvaring)INJECTION (Sayana Press)
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?)*

LEVONORGESTREL (e.g. Elevin, Levest, Logynon, Maexeni, Microgynon, Ovranette, Rigevidon & TriRegol)DESOGESTEROL (e.g. Bimizza, Cimizt, Gedarel, Marvelon & Mercilon)GESTODENE (e.g. Akizza, Femodene, Femodette, Katya, Millinette & Sunya)DROSPIRENONE (e.g. Dretine, Lucette, Yacella, Yasmin & Yiznell)NORGESTIMATE (e.g. Cilique & Lizinna)NORETHISTERONE (e.g. Brevinor, Norimin, Norinyl-1 & Synphase)NOMEGESTROL (e.g. Zoely)DIENOGEST (e.g. Qlaira)Other
Please tell us the brand you are currently using:*

Progestogen-only contraception
Which progestogen-only oral contraception?*

DESOGESTEREL 75microgram tablet e.g. Cerazette, Cerelle, Desomono, Desorex, Feanolla, Moonia & Zelleta)NORETHISTERONE 350microgram tablet (i.e. Noriday)Other
Please tell us the brand you are currently using:*

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)*
Up-to-date blood pressure (expressed as xxx/yy, e.g. 120/70)*
Please make sure the reading was taken within the past 3 months

Smoking history
What is your smoking status?*

Never smokedPreviously smoked, but now stoppedCurrently smoke (however frequently)
When did you start smoking?
e.g. 2010
Typically how many do you smoke per day?
e.g. 15 cigarettes per day
When did you stop smoking?
e.g. 2020
Typically how much did you smoke per day?
e.g. 5 cigarettes per day

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

No, no new partnersYes, I have had new partner(s)
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

Declaration
Comments:
Declaration (tick the box to agree):*

All of the information I have provided on this form is correct, up to date, and may be used to help make a decision on my contraception by the University Health Service.
Should be Empty:

Contraception request