Combined Pill Review

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Please read and complete this form to continue your prescription for the Combined Pill.

This pill type includes Rigevidon, Levest, Gedarel, Microgynon, Yasmin, Loestrin and many more!

Information regarding the benefits and risks of this pill can be found here NHS.UK COCP

Name*
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Please confirm that you have read and considered the above information about the Combined Pill*

Have you had breast cancer, a stroke or a heart attack?*

Have you ever had a blood clot or a migraine with aura?*

Do you smoke?*

Have you considered a more reliable form of contraception such as the coil, implant or injection? (see below)*

Are you happy with your pill?*

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.
Consent*

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