Please enable JavaScript in your browser to complete this form.First Name *Last Name *Date of Birth *Mobile Number *What is your blood pressure (within the last month)? *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 What is your height? *What is your weight? *If your BMI ≥ 30 and you are on the combined pill then please book an appointment with a doctor What contraceptive medication are you taking? *Eg. Combined Pills –Microgynon/Rigevidon/Levest/Ovranette, Cilest/Zeletta, Loestrin 20/30, Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell , Evra patch, Nuvaring Progestogen-Only Pills –Desogestrel/Cerazette/Cerelle, Femulen, Norgeston, Micronor/Noriday, Microval Any problems with using your contraception or side-effects from it? *NoYesAny new/unusual bleeding? Eg. Between periods/during or after intercourse *NoYesAny changes in your Personal or Family History (mother or sibling) including Breast cancer/ Thrombosis (blood clots in legs veins or lungs)?NB You may be able to continue the contraception, but we would like to discuss this with you *NoYesFor combined pill/patch/vaginal ring users only - Have you ever had a migraine with aura – ie. Visual disturbance which occurs prior to the onset of a migraine/headache? *NoYesIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE MAKE AN APPOINTMENT WITH THE PRACTICE NURSE/PHARMACIST/PHYSICIAN ASSOCIATE/GP. We cannot issue a prescription until you have been reviewed.Do you smoke? If so how many per day? *please be aware that for the combined pill if you smoke heavily or have another relative risk factor we cannot prescribe this medicationAlthough 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. Smear test . If you are over 25, have you had a smear test in the past 3 years/or as recommended after your last smear test? If you have had one privately or abroad please email us the result. DECLARATION I understand that the contraceptive pill has certain risks attached to it, as outlined in the patient information leaflet included with the pills, and that smoking increases these risks. I agree to all the above information is accurate Please Choose...YesNominated Pharmacy *Village Pharmacy -NW3 4AXBoots Pharmacy - NW3 6JPSuperdrug - NW3 6JPGreen Light Pharmacy - NW3 3NRBoots Pharmacy - NW3 4QGKeats Pharmacy Ltd - NW3 1NHOther [please include name and postcode]We can send your medication electronically to a nominated pharmacy of your choice to be ready for collectionNominated Pharmacy [Other]Message for GP (if required)Please ensure you have completed the HEIGHT, WEIGHT and BLOOD PRESSURE fields with values taken in the past week. We cannot process the request if these section are not completed Please allow for 5 working days for your request to be processed. Provided that the form is completed satisfactorily and there are no issues, a prescription will be sent to your nominated pharmacy or it will be printed and left in the reception. If there are risks or other issues identified, for your own safety we will request you book a review with a clinician.NameSubmit