MMP Contraceptive Pill Review Form

Please use this form if you have made a contraceptive pill prescription request. The receptionist will make a screening appointment with a clinician and you may get a call from our receptionist if there is a need for a further discussion.

Please do not use this form if you want to discuss or are considering starting contraception; instead, call the practice to make a nurse appointment.

Personal and prescription details

What is your name? *

What is your date of birth? *

What is your mobile telephone number? *

Please type in the name of the contraceptive medication you are taking *

Which best describes your pill taking regime? *

I take the pill every day

I take the pill every 21 days, followed by 7 pill-free days, and then restart

I take the pill for 9 weeks, followed by 4-7 pill-free days, and then restart

I take the pill every day until I start bleeding, which is when I stop taking the pill for 4-7 days, and then restart

Other (Please free text in the next question)

(If you have ticked "other" pill taking regime, please type below

Please type in the chemist you want the prescription to be sent to, or indicate if you want to collect it from the surgery. *

Clinical risks and benefits of the contraceptive pill

The contraceptive pill is a medication that you swallow at the same time each day to prevent pregnancy and when taken correctly, it is over 99% effective at preventing pregnancy. In real-world use, about 8 in 100 people who use the combined pill a year become pregnant due to incorrect use such as forgetting to take pills (92% effective).

The contraceptive pill can also be used to treat period pain, heavy periods, premenstrual syndrome (PMS), endometriosis, acne, polycystic ovary syndrome (PCOS) and adenomyosis.

There are some risks of using the pill, but these are not common, which include blood clots in an artery or vein; and a slightly increased risk of cervical cancer, breast cancer and liver cancer. Due to these risks, we ask you to complete the below information.

More information is on the NHS Inform website: Click here for more details.

I HAVE READ AND UNDERSTAND THE INFORMATION GIVEN ABOVE. (If you tick no, or do not understand this information, then you will get a call from our receptionist to make a clinician appointment) *

Yes No

I WISH TO CONTINUE WITH CONTRACEPTIVE. (If you tick no, then you will get a call from our receptionist to make a clinician appointment.) *

Yes No

I WISH TO HAVE A DISCUSSION ABOUT MY CONTRACEPTION WITH A CLINICIAN FURTHER. (If you tick yes, then you will get a call from our receptionist to make a clinician appointment) *

Yes No

Contraceptive Pill Clinical Information

If you have read, understand, and are happy to continue with your contraception and you do not wish to discuss it further, the clinician will look at the answers you provide to the clinical information below.

The practice may contact you to clarify information, but if the clinician is happy with your answers they will issue and send the prescription for you on the date that the receptionist organised the clinician screening review for you to the chemist that you have indicated above.

If you have asked for a further clinician discussion for contraception, or the clinician wants an additional conversation, the receptionist will call you for an appointment.

To help the clinician with the prescription, please could you answer a few of the following questions:

BMI Calculation Link

Please also click on the links below for more information about the pill, specifically the:

We recommend patients who take the pill to self examine breasts for any lumps and to contact GP should there be any changes. Please click on this link to the Coppafeel website for more information.

Optional Feedback

We would be grateful if you could provide your feedback regarding using this online form.

How did you find completing this form?

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Would you prefer to use this service or attend the surgery for your review

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We would be grateful if you could provide any feedback or comments about this service. Thank you.

Data Protection and Consent

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 13 February 2025
Page created: 16 August 2023

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MMP Contraceptive Pill Review Form

MMP Contraceptive Pill Review Form

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