Home
Accessibility Statement
Ante-Natal Self Referral for Maternity Care
Book Appointment
Change of Patient Details
Contraception
COVID-19 Corona Virus – Information for Patients
Order a Repeat Prescription
Southern Trust Physiotherapy Self Referral
USEFUL FORMS
Dates of Closure 2021
Privacy Statements
Surgery Closure for Staff Training Afternoons 2021
News
Services
Cancer Screening
Staff
Information
Out of Hours
Contact
Health Information

Abbey Court Surgery

Contraception

If you are human, leave this field blank.

For contraceptive requests and reviews. Please complete this form.

Name: *

Date of Birth: *

Address *

Contact Number: *

Contraception: *

New

Review

Date of last menstrual period: *

Do you have regular periods? *

Yes

No

Have you had unprotected sex since your last period? *

Yes

No

What is your preferred method of contraception? Please follow the link below if you are unsure of what contraception method to choose. *

https://patient.info/sexual-health/contraception-methods/

Medical Background

Do you suffer from any of the following conditions?

Migraines: *

Yes

No

Epilespy: *

Yes

No

High Blood Pressure: *

Yes

No

Deep Vein Thrombosis (leg clots/ lung clots) : *

Yes

No

Previous history of ectopic pregnancy? *

Yes

No

Personal history of breast cancer? *

Yes

No

Family History

Family history of blood clot in legs or lung? *

Yes

No

If Yes what relation is this family member to you?

Family history of breast cancer? *

Yes

No

If Yes what relation is this family member to you?

Social History

Smoking Staus: *

Smoker

Non Smoker

Ex Smoker

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

Please leave this blank

Disclaimer | Cookies