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: 16/10/2020

Your Details





Contraceptive Pill Review











Cardiovascular Risk





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

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






Do you have any liver problems







Are you aware:







Further Questions For A Current User:








FOR NURSES USE ONLY: