Prescription Form for Re-order of Combined Oral Contraceptives

Please note:

If you have not been reviewed by a nurse with in the last 12 months, please contact reception on 01727 851589 to book an appointment with a nurse. We will not be able to process your request without an annual review.
It is an essential requirement to let us know about your recent blood pressure readings. We will not be able to process your re ordering without your recent blood pressure reading.

Contraceptives Re-Order Form

Name: *

Date of Birth: *

Address:

Phone number: *

Date of request:

Do you smoke?

Yes

If you are over 35 years and you smoke more than 15 cigarettes a day, you should not be taking the combined oral contraceptives. Please contact reception to speak to a clinician.

Do you suffer with migraines?

Yes

Do you have a family history or blood clotting?

Yes

Please contact reception on 01727 851589 to book an appointment/ telephone consultation.

Height

Weight

Based on your height and weight we will calculate your Body Mass Index (BMI). If your BMI is greater than 35, we will contact you to discuss about your options.

What was your recent blood pressure reading? *

Parkbury House have a dedicated blood pressure machine for patient use in our reception area. The instructions are very simple to follow. One of our reception staff will be happy to help if required.

Name of Combined Oral Contraceptive you are requesting for: *

Please allow 2 full working days before collecting your prescription- after 4 pm.

Parkbury House Surgery

Prescription Form for Re-order of Combined Oral Contraceptives

Parkbury House Surgery Online