Contraceptive Pill

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This form is to be used for the following reasons:

  • If you want a repeat of your current contraceptive
  • If you have been advised by a clinician to complete this form
  1. Once this form is completed it is passed to a clinician to review.
  2. Once contraceptives are issued you will receive a text to collect your prescription at your nominated pharmacy.
Do you wish to start a new contraceptive or switch to a different contraceptive: *

In addition to completing this questionnaire you will also be required to submit an online consultation


All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
We need this to send you a text when your prescription is ready
May be used to identify you
We need this to be able to issue your prescription
Is this your usual nominated pharmacy?: *
Contraception Pill Review
Do you need a repeat of your current contraception?: *

Please check your blood pressure (if you do not have access to a blood pressure monitor or weighing scales, please call reception to book a blood pressure appointment. A recent reading (within the last 6 months) will suffice

Smoking status: *
When did you quit smoking?: *
Do you have a history of abnormal smear tests?: *

If you are due for a smear please book an appointment as soon as possible.

Do you have bleeding in between your periods?: *
Do you have bleeding after sexual intercourse?: *
Do you examine your breasts regularly?: *

Oral Contraceptives Risks

Hormonal contraceptives are medication that women take which contain hormones (such as oestrogen and progesterone) to prevent pregnancies. These medication come with many benefits, but can present with 
some small risks. It is important to be aware of these risks. The risks differ depending on the type of contraceptive you are on.

There are two types of oral contraceptives, if you are not sure which type you are on please consult your Pharmacist or Clinical Professional

Combined oral contraceptives (COC) risks

  • Increased risk of venous thromboembolism (blood clot), this can include increased risk of heart attack and stroke. If you have any history of heart conditions, COC may be contraindicated.
  • Small increased risk of breast and cervical cancer (if taking longer then 5 years), which reduces with time after stopping COC.

Progesterone-only pill (POP) risks

  • Some women get ovarian cysts (fluid-filled lesion), which can present with pelvic pain.
  • Small increased risk of breast cancer, which reduces with time after stopping POP.
  • If you do become pregnant while on the POP there is an increased risk of ectopic pregnancy

Addtional Resources

Do you currently have or have you ever previously suffered from the following?: *
Does anyone in your family have a history of any of the following?: *
Are you aware of the risks associated with taking oral contraception?: *

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