Personal information Name(Required)
First name
Surname
Address(Required)
The information below is required for anonymous reporting for health planning. The information in reports cannot be linked to you as an individual and will only be shared for NHS monitoring and research purposes.
Do you need an interpreter at the face-to-face appointment?(Required)
Type of contraception Type of contraception(Required) Please choose whether you would like a prescription for
Combined hormonal contraception - new or repeat supply?(Required) Progesterone only contraception - new or repeat supply?(Required) Contraception injection - new or repeat supply?(Required) A nurse may contact you if we need more information, please be aware this could be from a 'private' number.
Consent(Required) I consent to key information being shared with the pharmacy of my choice in order for them to safely dispense my chosen contraception.
Progestogene only pill Have you taken the progestogen only pill before?(Required) Have you ever been told by a healthcare professional that the progestogen only pill might not be suitable for you?(Required)
Gynaecological and postnatal history Have you been at risk of pregnancy in the last three months?(Required) You may have been at risk of pregnancy if:
Have you had a ‘normal’ period or bleed in the last four weeks?(Required) By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.
Have you experienced any unusual vaginal bleeding in the last two years?(Required) By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.
Are you up to date with your smear test?(Required) Have you had any new sexual partners within the last three months?(Required)
Up next, questions about your health
Please read each question carefully. If you answer yes, you may be asked to provide some more information, please answer as fully as you can.
Are you currently taking any medication or herbal remedies?(Required) Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.
What medication or herbal remedies are you taking, and what conditions are you taking these for?(Required)
Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?(Required) Are you allergic to any medications?(Required) This includes oestrogen and progestogen, the hormones in contraception. medroxyprogesterone acetate methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216) or sodium?
Please let us know what medication you are allergic to and what happens if you take it(Required)
Are you allergic to any food or drink, such as lactose, soy, nuts etc?(Required) Please let us know what you are allergic to and what happens if you consume it. For people who are allergic to lactose, are you able to tolerate a small amount in tablets? For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment.(Required)
Please also tell us if you are happy to proceed(Required)
Up next, questions about your health and family history
Again, please read each question carefully and answer as fully as you can.
Have you ever had thrombosis (blood clots), a stroke or a heart condition?(Required) Hormonal contraception can sometimes cause an increased risk of blood clots.
Have you ever had breast cancer or an undiagnosed breast lump?(Required) Hormonal contraceptives can sometimes cause an increased risk of breast cancer.
Have you ever had liver problems or jaundice (you do not need to tell us about newborn jaundice)?(Required) Some hormonal contraceptives may be unsuitable for people with serious liver conditions.
Have you ever had gastro-intestinal (bowel) or gallbladder problems?(Required) For example, gallstones, inflammatory bowel disease, weight loss surgery or haemolytic uraemic syndrome. Changes to your gut can prevent contraceptives from being effective or could cause other health complications.
What gastro problems do you have?(Required)
Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?(Required) For example:
porphyria
systemic lupus erythematosus (SLE)
arterial disease
coeliac disease
treatment for a hormone dependant cancer (e.g. breast, ovary, uterine, cervical or endometrial)
functional ovarian cysts or complications in pregnancy (e.g. jaundice, ectopic pregnancy or trophoblastic disease).
What serious health issues have you had?(Required)
Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?(Required) Are you currently or have you ever experienced any of the below? Would you like one of our clinicians to call you to discuss and offer additional support/advice?(Required) Are you currently taking any medication or herbal remedies?(Required) Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.
Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?(Required)
Combined hormonal contraceptive Consent(Required) Please tick to confirm you have read and understood the above and attached links regarding your chosen method of contraception.
Have you ever taken the combined pill before?(Required) Have you ever been told by a healthcare professional that a combined contraceptive (pill, patch or ring) might not be suitable for you?(Required)
Next, we will ask you about your recent blood pressure What was your most recent blood pressure measurement?(Required) Your health may be at risk if you provide inaccurate answers, for some people, combined hormonal contraceptives can make their blood pressure higher. Unmanaged high blood pressure puts you at increased risk of stroke or heart attack. Please do not continue unless you are sure this is a true reading from within the last year. Getting a blood pressure reading is easy.
What is your height (in centimetres)?(Required) We need your height to calculate your BMI (body mass index).
If you have a high BMI and you use a combined hormonal contraceptive (pill, patch or ring) then there is a significantly increased risk of you having a blood clot, stroke or pulmonary embolism.
If you know you have a BMI over 34, you may want to consider ordering the progestogen only pill or the contraceptive injection instead.
What is your weight (in kilograms)?(Required) We need your height to calculate your BMI (body mass index).
If you have a high BMI and you use a combined hormonal contraceptive (pill, patch or ring) then there is a significantly increased risk of you having a blood clot, stroke or pulmonary embolism.
If you know you have a BMI over 34, you may want to consider ordering the progestogen only pill or the contraceptive injection instead.
Gynaecological and postnatal history Have you had a baby in the last two months?(Required) If you have recently had a baby and have other risk factors, combined contraceptives (pill, patch or ring) may not be suitable for you at this time. If this is the case, our clinicians will help you consider your options once they have reviewed your order.
Are you breastfeeding or chestfeeding?(Required) If you’re breastfeeding, pumping or chestfeeding, it can affect the type of contraception that is most suitable for you and your baby. So even if you’re only doing night or day feeds, or you’re mixed feeding, let us know.
Have you been at risk of pregnancy in the last three months?(Required) You may have been at risk of pregnancy if:
you have had sex without a reliable method of contraception
you have missed pills or have not been using your current method of contraception perfectly
you have recently suffered from excessive vomiting or diarrhoea
you are taking hormonal contraception and an interacting medication (for example, for HIV, TB, epilepsy, or the antibiotics rifampicin or rifabutin).
Please tell us more(Required)
Have you had a ‘normal’ period or bleed in the last four weeks?(Required) By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.
Have you experienced any unusual vaginal bleeding in the last two years?(Required) By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.
Are you up to date with your smear test?(Required) The cervical screening programme recommends smear tests every three years for women aged 25-49 and every five years for women aged 50-64.
Have you had any new sexual partners within the last three months?(Required)
Up next, questions about your health you’re your family history
Again, please read each question carefully and answer as fully as you can.
Do you have diabetes?(Required) Do you have limited mobility?(Required) There is a possibility of increased risk of blood clots if you are immobile for prolonged periods of time. For example, are you a wheelchair user, bed-bound or you will be undergoing major surgery with limited mobility during recovery.
Have you ever had a blood clot, stroke or mini-stroke, heart disease, heart attack, irregular heartbeat, high cholesterol or problems with your heart valves?(Required) This may include venous or arterial thrombosis, pulmonary embolism, transient ischaemic attacks (TIAs) or hypertension. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of blood clots.
Has anyone in your immediate family had a blood clot (thrombosis), pulmonary embolism (PE), stroke or heart attack under the age of 45, or been diagnosed with inherited high cholesterol or an inherited blood clotting disorder at any age?(Required) For example, a parent, grandparent, sibling or child, who has had blood clots, a stroke, heart disease or heart attack when they were under 45. Including venous or arterial thrombosis, pulmonary embolus, TIAs, hypertension or high cholesterol. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of blood clots.
Have you ever had breast cancer or an undiagnosed breast lump?(Required) Hormonal contraceptives can sometimes cause an increased risk of breast cancer.
Do you have two or more immediate relatives who have had breast cancer? Or are you a carrier of any genes that predispose you to breast cancer, specifically BRCA1 or 2?(Required) Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of breast cancer. Therefore, if you have a parent, grandparent, sister or child who has or has had breast cancer you may want to consider ordering the progestogen only pill or the contraceptive injection instead or think about having a coil fitted.
Have you ever suffered from migraines or severe headaches?(Required) This includes headaches or migraines with an aura. Auras are changes to your vision and/or pins and needles or numbness, they can occur before, during or after a headache. Combined hormonal contraceptives (pill, patch and ring) can sometimes cause an increased risk of stroke, this risk is increased when someone experiences migraines with aura.
Please give us more information about your migraines(Required) When was your last migraine? Do you take any medication for migraines? Did they start before or after you started using a combined contraceptive? Do you see visual disturbances such as bright spots, prism or zig zag shaped lights? Do you notice speech difficulties, increased sensitivity to noise, vertigo (dizziness), tinnitus (ringing in your ears), pins and needles or numbness down the side of your face or spreading from your fingers up your arm? Do any of these symptoms begin within an hour of the headache starting?
Have you ever had an autoimmune disease such as systemic lupus erythematosus (SLE)?(Required) Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?(Required) For example:
hypertriglyceridaemia
rheumatoid arthritis
porphyria
hepatitis
severe depression
complications during pregnancy or after childbirth (such as chorea, pemphigoid gestationis, pruritus, trophoblastic disease or hyperprolactinaemia).
Medication and allergies Are you currently taking any medication or herbal remedies?(Required) Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take:
anything for HIV, TB, epilepsy
study smart drugs
herbal medicines (such as St. John’s Wort or weight loss tea)
contraception (if you have a coil, implant or injection, tell us when you had it and what type it is).
Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.
Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?(Required) Please let us know what you are allergic to and what happens if you consume it(Required)
For people who are allergic to lactose, are you able to tolerate a small amount in tablets?(Required)
For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment. Please also tell us if you are happy to proceed.(Required) Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?(Required) Combined hormonal contraceptives (pill, patch or ring) may increase the risk of heart disease for those who and are aged 34 or over.
If you used to smoke when did you stop?(Required) Are you currently or have you ever experienced any of the below? Would you like one of our clinicians to call you to discuss and offer additional support/advice?((Required)
Contraception injection (Depo Provera / Sayana Press self-administered injection) Have you ever used the injectable contraceptive before?(Required) Has a healthcare professional ever shown you how to use self-injectable contraception?(Required) What was your most recent blood pressure measurement?(Required) Your health may be at risk if you provide inaccurate answers, for some people, combined hormonal contraceptives can make their blood pressure higher. Unmanaged high blood pressure puts you at increased risk of stroke or heart attack. Please do not continue unless you are sure this is a true reading from within the last year. Getting a blood pressure reading is easy.
Have you ever been diagnosed with high blood pressure?(Required) We need to know this as the injectable may cause adverse complications for those with high blood pressure. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, clinician will call you to discuss.
Gynaecological and post-natal history Have you been at risk of pregnancy in the last three months?(Required) You may be at risk of pregnancy if you are: having sex without a reliable method of contraception; you have missed pills or have not been using your current method of contraception properly; you have recently suffered from excessive vomiting or diarrhoea; or you have recently changed your method of contraception. If you are concerned about your risk, please reply ‘Yes’ or text us for further support.
Have you had a ‘normal’ period or bleed in the last four weeks?(Required) By ‘normal’ we mean a period or bleed which you experience on a regular basis. This includes your contraceptive free week.
Have you experienced any unusual vaginal bleeding in the last two years?(Required) By ‘unusual’, we mean bleeding other than your typical period, or normal recovery after having a baby. We need to know even if you have had a diagnosis or the bleeding has stopped, so we can understand the cause before we prescribe.
Are you up to date with your smear test?(Required) There is a weak association between using the injectable contraceptive for five years or longer and abnormalities on cervical smear tests. The increased risk reduces after stopping the injection. If you use the injectable contraceptive then please stay up to date with your smear tests. The cervical screening programme recommends smear tests every three years for women aged 25 to 49 and every five years for women aged 50 to 64.
Have you had any new sexual partners within the last three months?
Up next, questions about your health
Please read each question carefully. If you answer yes, you may be asked to provide some more information, please answer as fully as you can.
Are you currently taking any medication or herbal remedies?(Required) Some medication can interfere with other medication or cause other health complications. We particularly need to know if you take: anything for HIV, TB, epilepsy study smart drugs herbal medicines (such as St. John’s Wort or weight loss tea) contraception (if you have a coil, implant or injection, tell us when you had it and what type it is). Each time you order, it's important you tell us everything you are currently taking as we cannot rely on historical information when reviewing new prescription requests.
Do you have any allergies (including peanut, soya allergies or are lactose intolerant)?(Required) Are you allergic to any medications?(Required) This includes oestrogen and progestogen, the hormones in contraception. medroxyprogesterone acetate methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216) or sodium? iWe need to know this as medroxyprogesteroneis an active ingredient in the injectable. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, a clinician will call you to discuss.
Please let us know what medication you are allergic to and what happens if you take it(Required)
Are you allergic to any food or drink, such as lactose, soy, nuts etc?(Required) Please let us know what you are allergic to and what happens if you consume it(Required)
For people who are allergic to lactose, are you able to tolerate a small amount in tablets?(Required)
For people with a soy allergy, we can prescribe soy-free medication however we cannot guarantee that it comes from a completely nut free environment. Please also tell us if you are happy to proceed?(Required)
Up next, questions about your health and family history
Again, please read each question carefully and answer as fully as you can.
Have you ever had thrombosis (blood clots), a stroke or a heart condition (inc. angina or heart attack), irregular heartbeat, high cholesterol, transient ischaemic attacks or problems with your heart valves?(Required) We need to know this as the injectable can cause an increased risk of blood clots. Therefore, we need to know if you have had high cholesterol, blood clots, strokes, heart disease, problems with your heart valves or heart attacks - this may include venous or arterial thrombosis, pulmonary embolus, transient ischaemic attacks (TIAs) or hypertension. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed.
Have you ever had breast cancer or an undiagnosed breast lump?.(Required) We need to know this as the injectable can sometimes cause an increased risk of breast cancer. Therefore, if you have or have ever had breast cancer in the past it may be unsafe to use the injectable. We also need to know if you have an undiagnosed breast lump. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, an will contact you to discuss. Hormonal contraceptives can sometimes cause an increased risk of breast cancer.
Have you ever had liver problems or jaundice (you do not need to tell us about newborn jaundice)?(Required) Some hormonal contraceptives may be unsuitable for people with serious liver conditions. We need to know this as the injectable may not be as effective due to the breakdown of progestogen by your liver. We do need to know if you have experienced jaundice during pregnancy. If you answer yes, you will still be able to complete this order form, but before your contraception is prescribed, an will call you to discuss.
Have you ever had gastro-intestinal (bowel) or gallbladder problems?(Required) For example, gallstones, inflammatory bowel disease, weight loss surgery or haemolytic uraemic syndrome. Changes to your gut can prevent contraceptives from being effective or could cause other health complications.
What gastro problems do you have?(Required)
Have you ever had any other serious health conditions, illnesses, major surgery or medical treatment that we should know about?(Required) For example:
porphyria
systemic lupus erythematosus (SLE)
arterial disease
coeliac disease
treatment for a hormone dependant cancer (e.g. breast, ovary, uterine, cervical or endometrial)
functional ovarian cysts or complications in pregnancy (e.g. jaundice, ectopic pregnancy or trophoblastic disease).
What serious health issues have you had?(Required)
Do you smoke, vape, use e-cigarettes or any other tobacco products including shisha pipes?(Required) If you used to smoke, vape or use e-cigarettes, when did you stop? Are you currently or have you ever experienced any of the below?(Required) Would you like one of our clinicians to call you to discuss and offer additional support/advice?(Required)
Pharmacy Consent(Required) I consent to key information being shared with the pharmacy of my choice in order for them to safely dispense my chosen contraception
Pharmacy in Canterbury(Required) Please pick the pharmacy you would like to collect your medication from:
Please select... Delmagate Pharmacy, 38 Broomfield Road, Broomfield, Herne Bay, CT6 7LY Eckersley Pharmacy, 2 Northgate, Canterbury, CT1 1WJ Park Pharmacy, 102 Kings Road, Herne Bay, Canterbury, CT6 5RE Swalecliffe Pharmacy, 5-7 St Johns Road,Swalecliffe, Whitstable, CT5 2QT Sturry Pharmacy, 8 High Street, Sturry, Canterbury, CT2 0BD Bridge Pharmacy, 16 High Street, Bridge, Canterbury CT4 5JY Paydens, 14 Cross Lane, Faversham, Kent ME13 8PN Porters Chemist, 2B Hales Drive, Canterbury , Kent , CT2 7AB Newton Place Pharmacy, Newton Place Surgery, Newton Road, Faversham, Kent ME13 8FH Superdrug, 23St Georges Street, Canterbury CT1 2SS Delmergate, 145 Reculver Road, Beltinge, CT6 6PD Delmergate, 269 Reculver Road, Beltinge, CT6 6SR
Pharmacy in Dover(Required) Please pick the pharmacy you would like to collect your medication from:
Please select... Paydens, The New Medical Centre, St Richards Road, Deal, Kent, CT14 9LF Golf Road Pharmacy, 37B Golf Road, Deal, CT14 6PY Queen Street Pharmacy, 17 Queens Street, Deal, Dover, CT14 6EY Paydens Pharmacy, New Balmoral Surgery, Canada Road, Deal CT14 7EQ The Strand, 51 The Strand, Walmer, Deal. CT14 7DP Paydens, 108 High Street, Dover, CT16 1EG Cairns, 51 London Road, Dover, CT17 0SP Grace Chemist, 127 Folkestone Road, Dover, CT17 9SG Walmer Pharmacy, 315 Dover Road, Walmer, Deal CT14 7NX White Cliffs Pharmacy, 141 Folkestone Road, Dover, CT17 9SG AA Beggs, 32 Pencester Road, Dover CT16 1BW Queen Street Pharmacy, 17 Queens Street, Deal, Dover, CT14 6EY
Pharmacy in Medway(Required) Please pick the pharmacy you would like to collect your medication from:
Please select... ASDA, 387 Maidstone Road, Chatham, ME5 9SD Delmergate Ltd, 21 Shirley Avenue.Chatham. ME5 9UR Karsons Pharmacy, 33 Pattens Lane, Chatham, ME4 6JR Fenns Chemist, Unit 9-10, Walderslade Centre, Walderslade, ME5 9LR Karsons Pharmacy, 69-71 City Way, Rochester, ME1 2BA Osbon Pharmacy, 1 Railway Street, Gillingham, ME7 1XF Osbon Pharmacy, 17 Duncan Road, Gillingham, ME7 4LA Medway Pharmacy, 465 Canterbury Street, ME7 5LJ Sunlight Pharmacy, Sunlight Centre, Richmond Road, ME7 1LX Knights Pharmacy, 39 Knights Road, ME3 9DT Hoo Pharmacy, 5 Main Road, Hoo, ME3 9AA J Spenceley Twydall, 1 Twydall Green, Rainham. Gillingham, ME8 6JX Ryders Pharmacy, 130 High St, Rochester, ME1 1JT Bod Pharma, The Dame Sybil Thorndyke Medical Centre, Longley Road, ME1 2TH
Pharmacy in Thanet(Required) Please pick the pharmacy you would like to collect your medication from:
Please select... Baxters, 164 Canterbury Road, Garlinge, Margate,CT9 5JW Paydens Pharmacy, 5-9 Hawley Street, Margate, CT9 1PU Courts Pharmacy, 156-162 Grange Road, Ramsgate , Kent, CT11 9PR Courts Pharmacy, 67-69 Station Road, Birchington, Kent, CT7 9RE Palm Bay Pharmacy, 35 Summerfield Road, Cliftonville, Margate, CT9 3EZ Paydens, 74-76 St Mildreds Road, Westgate on Sea, CT8 8RF Woolls Pharmacy, Palm Bay Avenue,Cliftonville, Margate, CT9 3NR Paydens, Dumpton Park Drive, CT11 8AD Paydens, 76 St Mildreds Road, Westgate CT8 8RF Northdown Pharmacy, 261-263 Northdown Road, Cliftonville, Margate Kent CT9 2PN Newington Pharmacy, 47-49 Newington road, Ramsgate, CT12 6EW Paydens, Minnis Road, Birchington CT7 9SF ASDA Ramsgate, 56 Chatham Street, Ramsgate, Kent CT11 7PR
Once your request has been processed we will text you to inform you when to collect your prescription from your chosen pharmacy.