Contraceptive Pill Review/Pill Repeat Request Form

If you have been advised by the surgery to submit a contraceptive pill review please use this form. It is intended for patients who have had the pill continuously for the last six months or longer and are aged 18 to 55.

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Contraceptive Pill Review/Pill Repeat Request

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
(in numerical digits e.g. '9' not 'nine')

Contraception Pill Review

Please ask reception about having this done.

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Please ask reception for our information regarding the importance of regular breast self-examination.

We will contact you to discuss

If you would like more information please see or book to discuss these options with our pharmacist or a doctor.

Would you like a sexual health screen? Please see for further details.