Combined Oral Contraceptive Prescriptions

IT WILL NOT BE POSSIBLE TO REVIEW OR PROCESS PRESCRIPTION FROM 24TH TO 26TH OF DECMBER INCLUSIVE

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

​IT WILL NOT BE POSSIBLE TO REVIEW OR PROCESS PRESCRIPTION FROM 24TH TO 26TH OF DECMBER INCLUSIVE

Combined Oral Contraceptive Prescription Request Form

IT WILL NOT BE POSSIBLE TO REVIEW OR PROCESS PRESCRIPTION FROM 24TH TO 26TH OF DECMBER INCLUSIVE