CONTRACEPTIVE PILL REVIEW

We can only accept height in cm and weight in kg. Please click here for a converter.

This form is for patients who have already had the Pill prescribed by a Chartfield Surgery GP. If you want to start taking the Pill, please arrange a GP appointment.

If you need to update your blood pressure, you can do this in the Surgery on our automated BP machine. Take three readings and add the average result below.

I understand this form is not for Urgent Care. I am happy for Chartfield to contact me as appropriate and for this information to be entered into my medical record. I am submitting this information for myself or as the authorised proxy of someone else.

Please complete all fields to submit.

CHARTFIELD SURGERY

DO NOT ATTEND THE SURGERY UNLESS INSTRUCTED BY A CLINICIAN. FACE COVERINGS ARE MANDATORY.

PATIENT INFORMATION: PLEASE BE WARY OF COVID-19 VACCINATION SCAMS

CONTRACEPTIVE PILL REVIEW