Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

This form will be sent to Heathcote Medical Practice, Tadworth, KT20 5TH. Please ensure you have accessed the correct website before sending your request.

New Contraceptive Pill Review

About You

In Metres
In KG
Are you a smoker? *
Would you like help giving up?

Blood Pressure

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Contraception Pill Review

Are you aware of what to do if you miss a pill? *
Are you aware that the contraceptive pill may not work if you have diarrhoea, have been vomiting or are on antibiotics? *
Are you aware that the contraceptive pill does not protect you from sexually transmitted infections, so you will need to use a condom as well to protect yourself? *

Do you suffer from severe headaches or migraines? *
Do you experience visual symptoms or changes in sensation or muscle power on one side of you body? *
Do you have parents or siblings who have had heart disease or stokes under the age of 45? *
Do you have diabetes? *
Have you had a deep vein thrombosis or pulmonary embolus? *
Do you have parents or siblings that have had a deep vein thrombosis or pulmonary embolus under the age of 45? *
Do you have any blood clotting illnesses / abnormalities? *
Do you have any family history of breast cancer under the age of 50? *

Are you aware of the alternatives such as long acting reversible contraception (LARC)? *
For information regarding LARC, please read our Long Acting Reversible Contraception (LARC) information.
Would you like to book a consultation with a doctor to discuss or arrange fitting of a long acting reversible contraceptive? *
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