Combined Pill Review "*" indicates required fields 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 COCPName* First Last Date of birth* DD slash MM slash YYYY Best mobile number to contact you*Please confirm that you have read and considered the above information about the Combined Pill* YesHeight* Weight* Blood Pressure* Have you had breast cancer, a stroke or a heart attack?* YES - The practice will contact you No Have you ever had a blood clot or a migraine with aura?* YES - The practice will contact you No Do you smoke?* Yes Yes - I WOULD LIKE SOME HELP STOPPING No Have you considered a more reliable form of contraception such as the coil, implant or injection? (see below)* I am not interested in long acting contraception I WOULD LIKE CONTACTED BY THE PRACTICE FOR INFORMATION ON THIS COIL Information IMPLANT Information INJECTION Information Are you happy with your pill?* Yes, please CONTINUE my medication for the next year No, I would like to DISCUSS this with a clinician Comments Optional 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* I agree to the privacy policy.© 2022 Kristian TurnbullCAPTCHA OptionalComments OptionalThis field is for validation purposes and should be left unchanged.