For contraceptive requests and reviews. Please complete this form.

Contraception: *
Do you have regular periods? *
Have you had unprotected sex since your last period? *

Medical Background

Do you suffer from any of the following conditions?

Migraines: *
Epilespy: *
High Blood Pressure: *
Deep Vein Thrombosis (leg clots/ lung clots) : *
Previous history of ectopic pregnancy? *
Personal history of breast cancer? *

Family History

Family history of blood clot in legs or lung? *
Family history of breast cancer? *

Social History

Smoking Staus: *

Please contact reception to make an appointment for a blood pressure and weight check in the treatment room.