Prescription Form for Re-order of Combined Oral Contraceptives

Contraceptives Re-Order Form

Name: *

Date of Birth: *

Address:

Phone number: *

Date of request:

Name of Combined Oral Contraceptive you are requesting for: *

Are you pregnant?

Yes

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.

Have you had breast cancer?

Yes

Do you have a family history of liver disease?

Yes

Do you have a family history of breast cancer?

Yes

Do you have a family history of a blood clotting disorder?

Yes

Do you suffer with migraines?

Yes

If answered yes to any of the above, 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.

Parkbury House Surgery

Prescription Form for Re-order of Combined Oral Contraceptives

Parkbury House Surgery Online