Repeat Oral Contraceptive Pill

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Personal Details

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Name of pill requested: *

Nominate a pharmacy of your choice and this pharmacy will receive your prescription directly from your GP, via the Electronic Prescription Service (EPS). With EPS you will not have to visit your practice to pick up your paper prescription anymore.

HOW ELECTRONIC PRESCRIPTIONS WORK

Please provide a blood pressure reading taken within the previous month (systolic/diastolic e.g. 125/75). You can get your blood pressure checked at a pharmacy or book an appointment with the healthcare assistant

Upper Reading

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Have you had a baby in the previous 6 weeks?: *

Do you currently smoke: *

Have you stopped smoking within the previous 12 months?: *

Have you ever had breast cancer: *

Do you have any undiagnosed breast symptoms : *

Are you known to have any breast gene mutation (e.g. BRCA1): *

Have you ever had a blood clot in your legs or lungs (deep vein thrombosis or pulmonary embolism) : *

Are you known to have a blood clotting mutation (e.g factor V leidin, prothrombin mutation, protein C or S, antithrombin deficiencies)?: *

Have you ever been diagnosed with diabetes, high blood pressure, heart problems, stroke or high cholesterol?: *

Have you ever been diagnosed with a liver or gallbladder problem?: *

Have you ever been diagnosed with systemic lupus erythematosis (SLE) or with antiphospholipid antibodies?: *

Have you ever had a headache or migraine associated with visual disturbance, flashing lights, loss of vision, temporary numbness, paralysis or difficulty with speech?: *

Do you have any problems with your mobility (e.g. wheelchair, debilitating illness)?: *

Are you due to have any major surgery or have you had any major surgery in the previous 3 months?: *

Have any of your first-degree relatives had a blood clot in the legs or lungs (deep vein thrombosis or pulmonary embolism)?: *

What was the age of your first-degree relative when this happened?: *

Are you taking any over-the counter medication that we are not aware of?: *

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Declaration

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This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Repeat Oral Contraceptive Pill

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