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 this type of pill* Yes No Height* Weight* Blood Pressure* Have you had breast cancer, a stroke or a heart attack?* Yes No Have you ever had a blood clot or a migraine with aura?* Yes No Do you smoke?* Yes Yes - I WOULD LIKE SOME HELP STOPPING No Have you considered long acting contraception such as the coil, implant or injection?* I am not interested in long acting contraception I WOULD LIKE CONTACTED BY THE PRACTICE FOR INFORMATION ON THIS 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 CAPTCHA OptionalList Add RemoveName OptionalThis field is for validation purposes and should be left unchanged.