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Oral Contraceptive Pill Form

If you take an oral contraceptive pill, you need an annual review ('pill check') so that we can continue to prescribe it safely. (You may be due a review sooner than this if you have recently started or changed your pill) 

This form allows you to complete the pill check online - this is to make it quicker and easier for you to renew your prescription if your current pill suits you and you're happy to continue using it. 

(If you are having any problems or would like to discuss changing to a different form of contraception, we would ask you to please book an appointment with a GP) 

In addition to completing this from we also need your current weight and blood pressure. If you do not have the equipment to measure these at home then please make an appointment with one of the 

nurses. 

The information provided on this form will be sent to a GP for review and your request will usually be processed within 5 working days. If there are any issues you will be contacted to discuss the matter further. If there are no issues, we will not contact you and you may collect your prescription from the pharmacy. 

Are you experiencing any problems with bleeding after sex or bleeding between periods?:
Are you taking any other medication apart from your pill?:
Have you been diagnosed with any new health conditions since we last issued a prescription for your pill?:
Do you smoke?
Do you suffer from migraine headaches?
It is vital you do not take combined oral contraception if you have migraine with aura, as this is known to increase your risk of stroke.
Have you ever had a blood clot (eg in your leg or in your lung, often referred to as a DVT or a PE)?:
Has a close family relative (parent or sibling) ever had a blood clot?
Have you ever had breast cancer?
Has a close family relative (parent or sibling) ever had breast cancer?

Smear tests are an essential tool to prevent cervical cancer. https://www2.hse.ie/conditions/cervical-screening/ 

They are offered to everyone with a cervix between the age of 25 and 65. The screening interval is every three years for those aged 25 to 29, and every five years for those aged 30 to 65. You should receive an invitation to book from CervicalCheck when you are due. You should automatically be on the register if you are aged between 25 and 65 & have a PPS number. 

Are you up to date with your cervical screening?

If you have received this invitation, or if you believe you are due a smear after reading the above information, please do book a smear test appointment with our nurse.

You should be aware of other, more reliable long-acting methods of contraception, such as the Coil and the Implant. These are more effective than any pill taken by mouth. We can fit any of these at Millbrae - book a appointment with a GP to discuss further if you are interested.
You should be aware that no contraceptive pill is protective against sexually-transmitted infections
If you miss a pill, you may be at risk of an unplanned pregnancy. The rules for missed pills vary for the different types of pills.
Your health and safety is important to us and we need to ensure that we have sufficient information to complete this review. If at any time you have concerns about your pill then please book a nurse or GP appointment.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

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