Repeat Prescribing of Oral Contraceptive Pill (OCP) Form If you have been advised by the surgery to submit a contraceptive pill request, please use this form. Name of Contraceptive PillFull NameDate Of Birth DD slash MM slash YYYY Email Address (please print) Please double check you’ve entered the correct email addressPhone Number:Blood Pressure (Result & Date)Can get checked at the local pharmacyWeight (Result & Date)Smoking Status I have never smoked Currently smoke I used to smoke Cigarettes per dayDate I stopped smoking: DD slash MM slash YYYY If the above results are judged to be unsafe for continuation of the medication, you will be asked to see a practice nurse.Are you experiencing any problems or side effects using your contraceptive pill? Yes No Are you experiencing any problems with your bleeding pattern i.e. bleeding with sex or when not on a break from your pill? Yes No Have you or a member of your family had a history of blood clots or blood clotting disease? (i.e. DVT, PE or stroke) Yes No Do you understand what to do if you think you have missed a pill? This information is also available in the patient information leaflet. Yes No Is there any chance you could currently be pregnant? Yes No Do you suffer from migraines? Yes No If so, have you ever suffered from any sensory disturbance before or during a headache? (e.g. vision, smell, taste, hearing or physical sensation called ‘aura’) Yes No If aged 25 or over, are you up to date with your smear tests? This is normally done every 5 years. Yes No Under The Age Of 25 Are you currently taking any privately prescribed weight loss injections (e.g. Mounjaro, Ozempic, Wegovy?) The use of these medications can stop your pill working and increase your chance of pregnancy. Yes No Which pharmacy do you want the prescription to be sent to?DeclarationDeclaration: I understand that the contraceptive pill has certain risks associated with its use, as outlined in the patient leaflet previously provided with my pills, and that smoking increases these risks. The information provided is correct to the best of my knowledge.Name:Date DD slash MM slash YYYY A leaflet will be provided with your prescription that discusses long-acting contraceptive options, please contact the practice and ask for an appointment if you wish to discuss this further.Privacy ConsentThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Data Protection Policy to discover how we protect and manage your submitted data.Consent I consent to the practice collecting and storing my data from this form.