The Mini Pill Review Form

The Mini Pill — e.g. Desogestrel, Cerelle, Cerazette

We can offer a telephone/video review rather than having patients attend the surgery unnecessarily.

"*" indicates required fields

Name*

Email*

Date of birth*

Your Height and Weight

Unit of measurement*

Height in cm*

Weight in kg*

Height in ft*

Height in inches*

Weight in lbs*

Mini Pill Review

Are you happy with your current Pill ?*

Yes

Do you smoke?*

Yes

Do you understand and the risk and benefits of your current contraceptive?*

Yes

Have you considered the coil or implant?*

Yes

Best number to call you on*

The practice will be in contact. Any comments you would like to add?

Privacy Policy

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.

I consent to the practice collecting and storing my data from this form.

We need your consent to proceed. Please tick the box to consent.

Mull Medical Practice