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Do you live in England?

The NHS pharmacy contraception service is only available in England

Yes

Please enter your Full Name?

Your full name must match your GP records.

Please enter your NHS number below?

(optional — this helps us process your order faster) - Not sure where to find it? Check any NHS letter, prescription slip, or your NHS app.

Date Of Birth

Are you using any contraception currently?

Yes

Would you like to explore longer-term contraception options (such as LARC) with a healthcare professional?

LARC - Long-acting reversible contraception e.g. Implant - Nexplanon, Intrauterine device (IUD) - Coil, Intrauterine system - Hormonal Coil, Contraceptive Injection (Depo-provera),

Yes

Are you currently Pregnant or gave birth within the last 28 days?

Yes

Do you have any allergies or sensitivities to medications?

Including contraceptive pills or their ingredients

Yes

Do you have any of the following conditions?

History of blood clots or classed as high risk, immobile

Smoker - includes e-cigarettes

Migraine with aura or triggered by hormonal contraception

Breastfeeding

History of stroke, high blood pressure, clotting disorders, irregular heartbeat, heart disease

Cancer

None of the above

Are you currently on any medication?

This includes medication from your GP, over the counter, recreational and herbal.

Yes

Have you used Hormonal Contraception before?

Yes

What is your height?

Value must be between 100cm and 220cm

Switch to ft, in

What is your current weight?

Value must be between 40kg and 250kg

Switch to st, lb

Do you have any of the following conditions?

Liver conditions e.g. Liver disease, Gallbladder disease,

Surgery affecting absorption (e.g. bariatric surgery)

Kidney Disease , Renal Failure and High potassium levels

Diabetes with complications e.g. Retinopathy, nephropathy, neuropathy

Addisons disease, Porphyria, Organ Transplant

None of the above

Please enter your contact number in case we need to reach you?

What is your blood pressure?

Systolic BP

mmHg

Diastolic BP

mmHg

Arm

Left

Right

Do you feel safe in your personal relationships and living situation?

Yes

Is there any other information you feel would be useful for our clinicians to know about?

Yes

Do you agree to receive oral contraception from the pharmacist and consent to your information being shared with NHS England for service monitoring and evaluation, and with NHSBSA and NHS England for contract management and post-payment verification?

Yes

Do you give consent for us to inform your GP

If you give consent for data sharing, the information you provide will be passed to: your GP. To inform your GP that you have received oral contraception through the NHS Pharmacy Contraception Service.

Yes

DrPillmans

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