Contraceptive Repeat Request Form

You may request a repeat prescription of the pill, patch, ring or the sayana press self-administered contraceptive injection if:

This has been prescribed by our practice previously and/or you have been reviewed by a GP/Nurse/Physician’s associate here about this method within the last 2 years, and
You do not have any reasons why we should not continue to prescribe this method of contraception.

If you are experiencing any issues with your current contraception method, have any concerns or would like to consider an alternative form of contraception such as the coil, implant or depot injection, please book an appointment with one of our clinicians or click here to visit our contraception page.

For further information about the pill please click on the links below, if you still have any questions please book an appointment with one of our clinicians to discuss further.

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Personal Details

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Your Health

PLEASE NOTE WITHOUT A RECENT BLOOD PRESSURE WE CANNOT ISSUE COMBINED PILLS

If your blood pressure is above systolic (higher value) 140 mmHg or diastolic (lower value) 90 mmHg please repeat it three times and if it is still raised book an appointment to see a doctor.

PLEASE NOTE: THE COMBINED PILL & UNCONTROLLED BLOOD PRESSURE INCREASES THE RISK OF CARDOVASCULAR DISEASE COMPLICATIONS INCLUDING STROKES

If your body mass index ≥ 30 (weight (kg)/height (m2)) and you are on the combined pill then please book an appointment with a doctor

Your Contraception

Eg. Combined Pills –Rigevidon/Levest/Ovranette/Microgynon, Maexeni, Cilique/Zeletta, Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell, Eloine, Sunya. Progestogen-Only Pills –Desogestrel/Cerazette/Cerelle. Evra patch, Nuvaring, Sayana Press contraceptive injection

Any problems with using your contraception or side-effects from it?: *

Any new/unusual bleeding? Eg. Between periods/during or after intercourse: *

Any changes in your Personal or Family History (mother or sibling) including Breast cancer/ Thrombosis (blood clots in legs veins or lungs)?: *

NB You may be able to continue the contraception, but we would like to discuss this with you

Since starting the pill/patch/ring have you had any new onset of headaches or increased severity/frequency of headaches?: *

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE MAKE AN APPOINTMENT WITH THE PRACTICE NURSE/PHARMACIST/PHYSICIAN ASSOCIATE/GP.
We cannot issue a prescription until you have been reviewed.

For combined pill/patch/vaginal ring users only

Have you ever had a migraine with aura – ie. Visual disturbance which occurs prior to the onset of a migraine/headache? :

Do you smoke?:

Please be aware that for the combined pill if you smoke heavily or have another relative risk factor we cannot prescribe this medication

Declaration

Although the overall risk of having a blood clot as a result of taking the pill is small, for some women it may be a serious risk. The risk is increased if you smoke, travel on a long-haul flight (more than 3 hours), trek at an altitude greater than 2500m, have recently had an operation, or are bed-bound for a long period.

Smear test

If you are over 25, have you had a smear test in the past 3 years/or as recommended after your last smear test? If you have had one privately or abroad please email us the result.

Declaration

I understand that the contraceptive pill has certain risks attached to it, as outlined in the patient information leaflet included with the pills, and that smoking increases these risks. I agree to all the above information is accurate. Please ensure you have completed the HEIGHT, WEIGHT and BLOOD PRESSURE fields with values taken in the past week. We cannot process the request if these section are not completed

Please allow for 5 working days for your request to be processed. Provided that the form is completed satisfactorily and there are no issues, a prescription will be sent to your nominated pharmacy or it will be printed and left in the reception.

If there are risks or other issues identified, for your own safety we will request you book a review with a clinician.

Privacy Consent

This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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CONTACT DETAILS

West Hampstead Medical Centre
9 Solent Road
London
NW6 1TP

Tel: 0207 431 1588
Out-Of-Hours: 111

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