Contraceptive Pill Review

This form is for us to carry out a medication review without the need to come into the surgery, as long as you are well on the contraception you currently have and you provide as much information as required.


This form is only applicable to patients ages 18 and over, any patients under the age of 18 will still need to attend face to face appointments. If you are having any problems with your medication or would like to consider alternative contraception options, please speak to your named GP, who will be able to advise you.


Please read the following information before completing this form.

  • The contraceptive pill may not work if you have diarrhoea or vomiting.

  • Commonly used antibiotics don’t effect the efficacy of the contraceptive pill.

  • Medicines such as some of those used to treat epilepsy, HIV and TB may make the pill less effective.


For contraceptive advice and information on long acting reversible contraception please visit


Please remember to attend your cervical smear testing, every 3 years for women aged 25-50 and every 5 years for women ages 50-65.

Blood Pressure

Please provide both blood pressure readings below.

Contraception Pill Review

Are you a smoker?
Are you aware of what to do if you miss a pill?
Are you aware that the contraceptive pill does NOT protect you from sexually transmitted infections(STI)?
Do you suffer from Migraines with Aura?
Have you or your parents or siblings been diagnosed with heart disease or stroke under the age of 45?
Have you or any family member under the age of 45 had a deep vein thrombosis or pulmonary embolus (Blood Clot) in the leg or lung?
Do you have any personal or family history of breast cancer under the age of 50?
Do you suffer from DVT in your legs or PE in your lungs?
Are you aware of alternatives such as long acting reversible contraceptives?
Would you like to book a consultation with a doctor to discuss or arrange fitting a long acting reversible contraceptive?

If your Doctor is happy with this review, your prescription will be available to pick up at your nominated pharmacy in 5 working days.

Thanks for submitting!