Contraceptive Pill Review

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Find my NHS Number (opens in new window)

Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Do you know?

Do you know the best thing to do if you miss a pill dose?

Yes

Do you know that if you have been vomiting, suffering from diarrhoea or if you are on antibiotics that this impacts the effectiveness of the pill (i.e. it may not work).

Yes

Do you know that the contraceptive pill is to prevent pregnancy only, it will not prevent the transmission of sexually transmitted diseases or infections. To protect against these you should use a condom.

Yes

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Rough Hay Surgery (Training Practice) • 44b Rough Hay Road, Darlaston, West Midlands, WS10 8NQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.