NHS Pharmacy Contraception Service

1. Please provide your details:

First Name *

Last Name *

Date of Birth *

Gender *

Email Address:

Postcode:

Phone Number:

Consent to Access Your Summary Care Records?

2. Are you wishing to start a new contraceptive pill or restart a previously used pill?

Yes No

3. Have you previously had a supply of an oral contraceptive from your GP, sexual health clinic or pharmacy?

If you’ve had a contraceptive pill before, please provide the name and brand of this and note if you wish to remain on the same one.

3b. Are you wishing to change your current contraceptive pill?

Yes No

4. Have you had any problems with, or side effects from your current contraceptive pill?

Yes No

4b. Please tell us what side effects you have experienced:

5. Are you wishing to start/ continue with a combined-oral contraceptive?

Yes No

5b. Have you had your blood pressure checked in the last three months? If yes, please provide your latest blood pressure reading:

6. Are you pregnant, or might be pregnant?

Yes No

7. Do you have long periods of immobility?

Yes No

8. Do any of the below apply to you?

Smoker (including vaping/ e-cigarettes)
Type 1 or 2 Diabetes
Current or past history of ischaemic heart disease, vascular disease, stroke or transient ischaemic attack (TIA)
Current or past history of blood clots or clotting abnormalities
Current or past history of any heart disease
Current or past history of migraines
Current or past history of breast cancer
Current or past history of any other cancer

Yes No

8b. Please let us know what condition(s) you have:

9. Do you have any form of liver disease or liver impairment or kidney disease?

Yes No

10. Do you have any planned major surgeries?

Yes No

11. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

11b. Please provide more details:

12. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

12b. Please provide more details:

13. I can confirm that I have answered the questions to the best of my ability.

Yes

13b. Please select a suitable date and time to book your appointment for a video consultation on the next page. If you feel you need your contraceptive pill more urgently, or your circumstances change, please seek more urgent review from your GP/Sexual health clinic.

We need to speak with you

We have gathered enough information

Please use the link below to go book an video call consultation about your conditions, please note we will be able to tell you more and answer any questions during the consultation.

Cancel

Name	Purpose	Expiry
CFID	This is a session cookie and is necessary for the operation of the site.	1 day
CFTOKEN	This is a session cookie and is necessary for the operation of the site.	1 day
SBCOOKIECONSENT	This cookie allows us to remember what choices you made relating to cookies you want to use on this site	1 year

Name	Purpose	Expiry
__UTMA	Used to distinguish users and sessions. The cookie is created when the javascript library executes and no existing __utma cookies exists. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMB	Used to determine new sessions/visits. The cookie is created when the javascript library executes and no existing __utmb cookies exists. The cookie is updated every time data is sent to Google Analytics.	30 mins from set
__UTMC	Set for interoperability with urchin.js. Historically, this cookie operated in conjunction with the __utmb cookie to determine whether the user was in a new session/visit.	When browser closed
__UTMT	Used to throttle request rate, used by Google Analytics	10 minutes
__UTMV	Used to store visitor-level custom variable data. This cookie is created when a developer uses the _setCustomVar method with a visitor level custom variable. This cookie was also used for the deprecated _setVar method. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMZ	Stores the traffic source or campaign that explains how the user reached your site. The cookie is created when the javascript library executes and is updated every time data is sent to Google Analytics.	6 months from set

NHS Pharmacy Contraception Service

0115 850 1944

enquiries@thefamilychemist.co.uk

13 Poplars Court,
Nottingham,
NG7 2RR

Opening times

Today’s Responsible Pharmacist

Sign In