Mini Pill – Barclay Victoria Park

Example Cerelle, Cerazette, desogestrel and Noriday

Mini Pill

Complete the eReview below for a repeat of your mini progesterone only pill. You will not need to attend the surgery. Please research mini progesterone only pill before advancing with this eReview.

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Mini Pill Review

Are you happy with your current Pill ? *

Yes

What is your weight in kg eg 65 kg *

How tall are you? *

We need this to calculate your BMI

Do you smoke? *

Yes

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

Yes

Would you like to consider the coil or implant? *

Yes

Best number to call you on *

One of our clinicians will contact you on this number in the next couple of weeks.

Please add a comment about your contraception. The Practice will be in contact soon. *

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.