Contraception Request Form - Grays Inn Medical Group

Please allow up to 48 hours for your medication to be issued

Which practice are you registered with?

Gray's Inn Medical Practice
The Vauxhall Surgery
Daleham Gardens Health Centre
Fortune Green Practice

First Name *

Last Name *

Date of Birth *

Mobile Number *

What is your blood pressure (within the last month)? *

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

What is your height? (cm) *

What is your weight? (kg) *

Recorded within past week

What contraceptive medication are you taking? *

Eg. Combined Pills –Microgynon/Rigevidon/Levest/Ovranette, Cilest/Zeletta, Loestrin 20/30, Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell , Evra patch, Nuvaring Progestogen-Only Pills –Desogestrel/Cerazette/Cerelle, Femulen, Norgeston, Micronor/Noriday, Microval

Any problems with using your contraception or side-effects from it? Eg. Increased weight, nausea, headache/migraine, abdominal pain,etc *

No
Yes

If yes, please specify...

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

No
Yes

Any changes in your Personal or Family History (mother or sibling) including Breast cancer/ Thrombosis (blood clots in legs veins or lungs)? You may be able to continue the contraception, but we would like to discuss this with you *

No
Yes

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? *

No
Yes

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.

Do you smoke? If so how many per day? *

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

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 *

Nominated Pharmacy *

We can send your medication electronically to a nominated pharmacy of your choice to be ready for collection

Message for GP (if required)

Please allow for 2 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. If there are risks or other issues identified, for your own safety we will request you book a review with a clinician.

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