Combined Oral Contraceptive Prescriptions

THIS FORM IS FOR COMBINED ORAL CONTRACEPTIVE PRESCRIPTION REQUESTS, WE LIKE TO SEE OUR PATIENTS ON THESE MEDICATIONS ANNUALLY FOR A CHECK-UP IN PERSON PLEASE DO NOT USE THE FORM FOR ANYTHING OTHER THAN COMBINED ORAL CONTRACEPTIVE PRESCRIPTION REQUESTS

Combined Oral Contraceptive Prescription Request Form

* Indicates required field

Name Address Date of Birth *

Contact Number *

Nominated Chemist *

Name of Oral Contraceptive Pill *

When was your last annual pill check, a pill check involves seeing the doctor in person *

What is your approximate weight *

Do you know how to manage a missed pill *

Do you Smoke *

Do you suffer Migraines *

Do you have a history of Deep Vein Thrombosis or Pulmonary Embolus *

Have you a family of breast cancer under the age of 50 *

DO you have parents or siblings who have had heart disease or strokes under the age of 45 *

Submit

Contact Us
133 St Peter's Rd, Walkinstown, D12XN9F
Ph switch 4504168 Fax 4783175

23 Old Bawn Way, Tallaght, D24 TKP0
Ph switch 4504168