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Contraceptive Pill Review

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

Full Name:


Date of Birth:


Phone Number:


Email Address:


Do you regularly check your breasts?
Yes
No

Do you suffer from severe headaches or migraines?
Yes - But the Doctor is unaware
Yes - And the Doctor is aware
No

Are you experiencing any irregular bleeding?
Yes
No

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.