Combined Oral Contraceptive (COC)/Patch Checklist

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

Last Updated: 09/03/2021

Your Details







Contraceptive Pill Review














Cardiovascular Risk





*If you have more than one of the following risk factors for heart disease

*if more than one "yes" in below table, no supply.





Do you have any liver problems








If yes to any of the above risk factor, please speak with a GP

Are you aware:







LARC - (Long Acting Reversible Contraception)

An information sheet about LARC is available to download at the bottom of this page under Further Information - LARC (Long Acting Reversible Contraception)

Further Questions For A Current User:








FOR NURSES USE ONLY: