Contracteptive Pill Review Form - Tonyfelin Medical Centre

What contraception are you using?

What is the name of your contraceptive pill?

Why are you taking the pill? *

Birth Control

Period Control

Would you consider a long-acting reversible method such as the implant, injection, or coil as an alternative to the pill? *

Yes No

DISCLOSURE - This form collects your name, date of birth, email, other personal information, and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. By completing this form, you consent to the practice collecting and storing the data on this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Contraceptive Review Form

Further Information