Do you have any known allergies? *
If you smoke how many do you smoke per day?
If you've quit smoking, when did you stop?
Are you currently using Contraception? *
If Yes to currently using Contraception please give details of what you are using currently?
If you are aged 25 and over, are you up to date with your Cervical Screening? *
Are you awaiting referral to Colposcopy following a smear test? *
Do you have any of the following (please select)
Do you take any of the following?
If you have selected any of the above please give more details here
Do you have any of the following?
If you have selected any of the above conditions please provide further details
Have you researched the implant as a method of contraception? *
If No, please visit the NHS Website for further information such as possible side effects - https://www.nhs.uk/conditions/contraception/contraceptive-implant/ *
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 also 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. *