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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

Please specify the contraceptive pill (tablet) you are currently using?

This service is for oral contraception only.

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

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

Yes

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

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

Are you currently on any medication?

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

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

Has anything changed since your last supply?

This includes medical, surgical or mental health since your last supply of contraception

Yes

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

Please make sure your phone number is correct and answer the pharmacist’s call, as this may delay your order if we cannot contact you.

A pharmacist may need to call you before your order can be approved. What is the best time to call you?

You must answer the pharmacist’s call or return the call. If we cannot reach you, your order may be delayed.

What is your blood pressure?

Systolic BP

mmHg

Diastolic BP

mmHg

Arm

Left

Right

Where did you get your last supply of contraception from?

GP Surgery

Pharmacy

Sexual Health Clinic

Other

Do you have any of the following conditions?

History or family 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 including family history

None of the above

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

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, post-payment verification and access to your medical record?

Yes

Do you give consent for us to inform your GP?

Yes

DrPillmans

Progress

Repeat Contraception Consultation