Contraceptive Pill Repeat Prescription Request

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Repeat Prescribing of oral contraceptive pill (OCP) policy

Scope of document

This document is designed to provide clarity to clinical and administrative staff within Statham Grove Practice on the duration of supply of oral contraceptives (OCP) on prescription that can be provided to patients.

The durations of supply apply only to those patients who have been clinically assessed as being appropriate for OCP.

Patients newly starting an OCP

To see Specialist Nurse or a GP for a discussion about contraceptive options

If Specialist Nurse or GP deems patient appropriate for OCP the GP should prescribe up to three months of OCP

Patient requesting to continue on an OCP

Patients can request a further supply using the “Contraceptive pill repeat prescription request form” (see below)

Contraceptive pill repeat prescription request form to be given directly to Practice Nurse or in their absence the Practice Pharmacist or in their absence to a GP

Up to 12 months’ supply of OCP can be supplied based on clinical judgement

This can be repeated annually without face to face pill checks if clinically appropriate

Personal Details

If you have been advised by the surgery to submit a contraceptive pill request please use this form.

Please double check you've entered the correct email address

Can get checked in local pharmacy

Can use scales in waiting area of the surgery

May be used to identify you

Smoking Status

Please confirm your smoking status:

If the above results are judged to be unsafe for continuation of the medication, you will be asked to see a practice nurse.

Contraception Pill Review

Please answer all questions on the form by ticking the relevant box, sign and date the form and hand to reception.

Incomplete forms will not be processed. If you are unsure how to answer, please organise for appointment with a practice nurse.

Was the contraceptive pill first issued within the last 3 months?: *

Do you have any problems with your general health?: *

Do you have any problems or side effects using your contraceptive pill?: *

Do you understand the ‘missed pill rules’ for your particular type of contraceptive?: *

Do you have any health matters you wish to discuss with the GP or practice nurse?: *

Please book an appointment to see your doctor or the practice nurse

Do you believe there is a chance you could be pregnant? : *

Do you suffer from severe headaches, frequent headaches or migraines?: *

Please make an appointment to see your doctor to discuss your headaches if you have not already done so.

Have you ever suffered from visual or auditory disturbance prior to getting a headache?: *

Have you suffered vaginal bleeding between periods?: *

Have you suffered vaginal bleeding during or after sexual intercourse?: *

Have you suffered unusual discharge since last prescribed?: *

Have you had a history of blood clots or blood clotting disease?: *

Have you ever suffered from cancer?: *

Declaration

Declaration: I understand that the contraceptive pill has certain risks associated with its use, as outlined in the patient leaflet previously provided with my pills, and that smoking increases these risks. The information provided is correct to the best of my knowledge.

_{A leaflet will be provided with you prescription that discusses long acting contraceptive options, please contact the medical centre and ask for an appointment if you wish to discuss this further.}

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Contraceptive Pill Repeat Prescription Request

Repeat Prescribing of oral contraceptive pill (OCP) policy

Patients newly starting an OCP

Patient requesting to continue on an OCP

Please confirm your smoking status:

Privacy Consent

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