NHS Pharmacy Contraception Service - Tier 1 – Ongoing supply of oral contraception

Pre-consultation Screening for supply of your pill

Which type is your pill
This is so we can email your results over to you.
This is so we can text your results over to you.

CONSENT

I consent to the following information sharing that will take place:

Medical History

Do you have any allergies?
Are you currently regularly taking any other prescribed, over-the-counter or herbal medicines?
Please add any medication you have stopped in the last 4 weeks

Maximum file size: 67.11MB

Has there been any changes to your medical, surgical or mental health since the last supply of your oral contraceptive?
Are you pregnant, or might you be pregnant?
Have you had any problems with or side effects from your contraceptive pill?
Have you been diagnosed with Acute porphyria?
Do you have a current or past history of ischaemic heart disease, vascular disease, stroke or transient ischaemic attack (first attack only that occurred whilst taking this contraceptive)
Do you have a past or current history of breast cancer?
Do you have any past or current history of any other cancer?
Do you have any form of liver disease or liver impairment?
Do you have a current or past history of benign or malignant liver tumour (hepatocellular adenoma or hepatocellular carcinoma)?
Do you have a current or past history of severe (decompensated) cirrhosis?
Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?

Long-acting reversible contraceptives (LARCs) are highly effective form of contraception which are usually inserted intravaginally, into the arm or injected. They last between 13 weeks to 10 years depending on the type of LARC and therefore does not rely on daily pill-taking. Please see this website for further information: Contraception - https://www.sexwise.org.uk/contraception/long-acting-reversible-contraception-larc

Would you be interested in LARCS? (Long Acting Reversible Contraceptives)
Clear
This is so we can email your results over to you.
This is so we can text your results over to you.

CONSENT

I consent to the following information sharing that will take place:

Your numbers

Kilograms
metres
Systolic/DiastolicmmgHG
Recent (within 3 months)

Medical History

Do you have any allergies?
Are you currently regularly taking any other prescribed, over-the-counter or herbal medicines?
Please add any medication you have stopped in the last 4 weeks

Maximum file size: 67.11MB

Has there been any changes to your medical, surgical or mental health since the last supply of your oral contraceptive?
Are you pregnant, or might you be pregnant?
Have you given birth within the last 21 days?
Have you given birth within the last 6weeks AND are breastfeeding?
Have you had any problems with or side effects from your contraceptive pill?
Are you a smoker or have you stopped smoking less than one year ago? (including vaping / use of e-cigarettes)
Do you have significant or prolonged immobility?
Do you have a current or past history of any heart disease or have parents, siblings and children who have had heart disease or strokes under the age of 45?
Do you have any problems with your heart muscle or any impaired heart function?
Do you have or have you been diagnosed with atrial fibrillation?
Have you ever had deep vein thrombosis or pulmonary embolism or have parents, siblings and children who have had deep vein thrombosis or pulmonary embolism under the age of 45?
Do you have a current or past history of migraine with neurological symptoms at any age (including aura – visual symptoms or changes in sensation or muscle power on one side of your body)?
Do you have a past or current history of breast cancer or are known to be a carrier of gene mutations associated with breast cancer?
Do you have any past or current history of any other cancer?
Do you have any form of liver disease or liver impairment?
Do you have a current or past history of benign or malignant liver tumour (hepatocellular adenoma or hepatocellular carcinoma)?
Do you have a current or past history of severe (decompensated) cirrhosis?
Do you have gall bladder diseases which is currently symptomatic or medically managed?
Do you suffer from Cholestasis, a condition caused by blocked or reduce flow of bile fluid?
Have you had any bariatric surgery or any other surgery that has reduced your ability to absorb things from your stomach?
Do you have any planned major surgeries?
Do you have diabetes?
If yes, has this affected any of your organs (causing retinopathy, nephropathy, or neuropathy)
Have you ever been diagnosed with Anti phospholipid syndrome (APS) (also known as Hughes syndrome) with or without Lupus?
Have you ever had an organ transplant that has resulted in complications?
Do you have severe kidney impairment or acute renal failure?
Have you been diagnosed with Acute porphyria?

Long-acting reversible contraceptives (LARCs) are highly effective form of contraception which are usually inserted intravaginally, into the arm or injected. They last between 13 weeks to 10 years depending on the type of LARC and therefore does not rely on daily pill-taking. Please see this website for further information: Contraception - https://www.sexwise.org.uk/contraception/long-acting-reversible-contraception-larc

Would you be interested in LARCS? (Long Acting Reversible Contraceptives)
Clear