Contraceptive Pill Review

If you have been advised by the surgery to submit an annual contraceptive pill review please use the form below.

Please see this guide to long-acting reversible contraception (PDF)

What to do if you’ve missed taking your combined pill

Advice if you’ve missed taking your progestogen-only pill

Our website should not to be used to request medication.

Contraceptive Pill Review

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
In Metres
In Kg
Please specify the pill you are taking: *

Your Blood Pressure

Please provide a blood pressure reading and heart rate reading. For a list of validated home blood pressure monitors, visit or discuss with your pharmacy.

Smoking Status *

Contraception Pill Review

Have you noticed any breast lumps?

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

Do you suffer from severe migraines?
Do you ever have migraines with visual symptoms?

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

Is there any bleeding after intercourse?

Please book an appointment to see the practice nurse.

Is there a family history of any blood clotting disorders in your first degree relatives (mother, father, siblings)?
Are you breastfeeding?
Do you have a current or past history of Ischaemic heart disease?
Do you have a current or past history of breast cancer?
Do you have a genetic condition that puts you at a higher risk of breast cancer i.e. BRCA1 or 2 gene mutation?
Do you have any gallbladder or liver disease?
Do you have antiphospholipid syndrome?
Is there any persistent abnormal bleeding between periods?
Do you have any history of strokes?
Do you have a history of organ transplantation?
Do you have any history of heart disease?
Do you have any history of Diabetic Kidney or Eye disease?

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Do you consent your medications being sent directly to your pharmacy via repeat dispensing? *

For more information on Electronic Repeat Dispensing, please visit NHS Prescription Services: eRD information for patients


Assuming our GP is happy with the review, your medication review date will be altered and script sent to your nominated pharmacy.