Annual Contraceptive Medication Review

If you have been advised by the surgery to do so, please submit this form.

Please submit this form at least a month before your last prescription is due to be ordered.

The practice nurse will then review this form and assess if your medication can be reauthorized or if you need a follow up phone call with the nurse so we can complete an assessment before you can continue for a further year.

If you would like to consider the implant for contraception, please self refer to iCaSH (integrated Contraception and Sexual Health services) by contacting 0300 300 3030.

If you would like advice or want to order a free testing kit, please visit the iCaSH website.

Annual Contraceptive Medication Review

Annual Contraceptive Medication Review



Since your last medication review a year ago, have you been diagnosed with or do you suffer from any of the following? (Please tick as appropriate)

Blood Pressure

Please add your home blood pressure readings. If you do not have your own blood pressure machine, we recommend that you purchase one as part of your household health and wellness kit.


Do you currently smoke?

Please visit our Wellbeing Centre for further information on stopping smoking if you wish to quit.

Have you had any problems or side effects whilst taking your contraception?
Have you experienced any irregular bleeding or, if sexually active, bleeding after intercourse?
Do you take your contraceptive pill regularly?
Do you self examine your breasts monthly for any lumps?