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.

DO NOT ATTEND THE SURGERY UNLESS INSTRUCTED.

FACE COVERINGS ARE MANDATORY.

CONTRACEPTIVE PILL REVIEW