Contraceptive Repeat Request

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Contraceptive Repeat Request Form

Request a repeat prescription of the pill, patch, ring or the sayana press self-administered contraceptive injection.

Issues or concerns

If you are experiencing any issues with your current contraception method, have any concerns or would like to consider an alternative form of contraception such as the coil, implant or depot injection, please book an appointment with one of our clinicians or visit our contraception page.

Further information on contraception methods

I confirm: *

Choose all that apply

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All questions marked with a * are mandatory

Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Contraception Pill Review

What type of pill/patch/ring are you taking/required: *

Have you had any recent changes in your health that might affect your contraception?: *

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

Do you have any blood clotting abnormalities?: *

Do you have parents or siblings who have ever been diagnosed with a blood clot in their legs or the lungs (deep vein thrombosis or pulmonary embolus)?: *

Do you have parents or siblings who have had heart disease or strokes under the age of 55? : *

Do you have parents or siblings who have had breast cancer under the age of 50?: *

Have you given birth within the last 6 weeks?: *

Have you ever had a migraine with aura – ie. Visual disturbance which occurs prior to the onset of a migraine/headache?: *

Any new/unusual bleeding? Eg. Between periods/during or after intercourse?: *

Book an appointment to see a Clinician

You may be able to continue the contraception, but we would like to discuss this with you. We cannot issue a prescription until you have been reviewed.

How to book an appointment

You cannot continue with this form: *

Do you currently smoke or have you stopped smoking in the last year?: *

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Blood Pressure

If you do not have a machine at home, please come to reception and have your blood pressure and weight measured on the practice machine.

We require a set of results from the last 2 weeks

Higher number

Lower number

Book an appointment to see a GP

If your blood pressure is above systolic (higher value) 140 mmHg or diastolic (lower value) 90 mmHg please repeat it three times and if it is still raised book an appointment to see a doctor.

The combined pill & uncontrolled blood pressure increased the risk of cardovascular disease and complications including strokes

How to book an appointment

You cannot continue with this form: *

Body Mass Index (BMI)

Your Body Mass Index (BMI) is:

How your Body Mass Index (BMI) is calculated

Book an appointment to see a GP

Your body mass index ≥ 30 (weight (kg)/height (m²)) and you are on the combined pill - please book an appointment with a doctor

How to book an appointment

You cannot continue with this form: *

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Risks

Although the overall risk of having a blood clot as a result of taking the pill is small, for some women it may be a serious risk.

The risk is increased if you smoke, travel on a long-haul flight (more than 3 hours), trek at an altitude greater than 2500m, have recently had an operation, or are bed-bound for a long period.

Some medication can reduce the effectiveness of ‘the pill’

Always check with the pharmacist or prescriber if you are taking any new medication or suppliments
this includes St John’s wort which you should avoid

If you are over 25, have you had a smear test in the past 3 years/or as recommended after your last smear test?: *

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

If there are risks or other issues identified, for your own safety we will request you book a review with a clinician.

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Contraceptive Repeat Request