The Mini Pill Review Form

The Mini Pill — e.g. Desogestrel, Cerelle, Cerazette

All of this form needs to be completed before you prescription will be issued and you may still require a face to face/telephone appointment if it is felt necessary. Please complete this form at least 2 weeks before your prescription is due.

Different Contraceptive Choices

The mini pill ( progesterone only pill )

Mini Pill

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Your Height and Weight

Weight

Unit of measurement *

Height

Weight

Height

Inches

Weight

lbs

BMI

Underweight

Healthy

Overweight

Obese

Mini Pill Review

Are you happy with your current Pill ? *

Yes

Do you smoke? *

Yes

Do you understand and the risk and benefits of your current contraceptive? *

Yes

Have you considered the coil or implant? *

Yes

Best number to call you on *

One of our clinicians will contact you on this number in the next couple of weeks.

The practice will be in contact. Any comments you would like to add?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

The Mini Pill Review Form

Your Height and Weight

Weight

BMI

Mini Pill Review

Privacy Policy

Health A-Z

Live Well

Medicines Guide

Care & Support