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Bangholm Medical Centre

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Annual Birthday Reviews
Mental Health Resources
Send An Image
Request a Sickline
Practice Forms
Prescription Requests
Appointments
Vaccination Information
Our Services
Health Advice
A-Z of Community Resources
Become A Patient

Home
Language
Home
Meet The Team
Our Services
Health Advice
A-Z of Community Resources
Appointment Reminders
Contact Us

Progesterone Only Pill Review

Please note:

if you are aged 55+, please book a face-to-face appointment.
Age 50+ and would like to discuss how long you have taken your pill, please make a face-to-face appointment

If you are looking to start a family, we would encourage you to start taking folic acid when you stop your pill.

Last Updated: 05/02/2024

Your Contact Details

First Name: *

Surname: *

Date of Birth: *

Contact Number: *

Which pharmacy would you like your prescription sent to? *

Health Check

Height:

Weight:

Do you Smoke? *

Yes

No - Never Smoked

No- Ex Smoker

Is your cervical smear up to date? *

Yes

No

Unsure

Pill-Related Questions

Name of current pill *

Are you happy to continue on your current pill? *

Yes No

Have you experienced any side effects?

Are you aware of late/missed pill rules? *

Yes No

Are you aware that if you vomit within 2 hours of taking your pill, it may not be effective? *

Yes No

Do you struggle to remember to take your pill? *

Yes No

If you answered yes to the above, would you like an appointment to discuss other potential methods of contraception, such as implants, coils etc? *

Yes No

Are you concerned about any abnormal bleeding (bleeding between periods or during/after sex)? *

Yes No

Do you feel safe in your relationship? *

Yes No

What length of prescription would you like? *

3 months

6 months

1 year

Consent

Please tick this box if you consent to us storing the data provided in this form, and consent to us contacting you if necessary. *

I consent

Feedback

Here at Bangholm, we are always looking at ways to improve our patients access and experience.

This form has been created as part of our improvement project for 2023/24.

If you have any feedback for us, please do let us know!

Thank you

How useful did you find submitting this form, instead of waiting for an appointment? *

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