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Oak Tree Surgery

Whitethorn Drive Bridgend CF31 2PQ
01656 665353

Family planning online form/repeat contraceptive pill

We will be in touch within 5 working days from the time you submit your form.

First Name *

Last Name *

Date of birth *

Mobile number *

If you are aged 16 to 18 years old, are you in full-time education?YesNo

For those wanting to start a new contraceptive

What contraceptive would you like to start? *Progesterone only pillCombined contraceptive pill/patch/ringContraceptive implantHormonal CoilCopper coilDepo proveraNot sure, would like to discussI am not wanting to start any new form of contraception, I would like a repeat prescription or to discuss my current method

This website has lots of good information on contraception and it would be helpful if you had a look before the appointment Contraception Choices

For those wanting a repeat of their contraception

What contraceptive medication are you taking? *Eg. Combined Pills - Microgynon/Rigevidon/Levest/Ovranette, Cilest/Zeletta, Loestrin 20/30, Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell, Evra patch, Nuvaring Progestogen-Only Pills-Desogestrel/Cerazette/Cerelle, Femulen, Norgeston, Micronor/Noriday, Microval

Any problems with using your contraception or side-effects from it? Eg. Increased weight, nausea, headache/migraine, abdominal pain, etc *NoYes

If yes, please specify...

Any new/unusual bleeding? Eg. Between periods/during or after intercourse *NoYes

Any changes in your Personal or Family History (mother or sibling) including Breast cancer/ Thrombosis (blood clots in legs veins or lungs)? You may be able to continue the contraception, but we would like to discuss this with you *NoYes

Have you ever suffered from migraines? *NoYes

If so when was your last one?

Where did you get your contraception from last time? *Oak TreeFamily planning clinicOther, please give details

Enter details *

For patients requesting a new contraception or those on the combined pill/patch/ring – you must complete the following before we can offer a prescription

Do you smoke? If so, how many per day? *

What is your height? (cm) *

What is your weight? (kg) *Recorded within past week

For those who are wanting a prescription of a combined pill ( Microgynon/Rigevidon/Levest/Ovranette, Cilest/Zeletta, , Mercilon/Gedarel 20, Marvelon/Gedarel 30, Femodene/Katya/Millinette, Yasmin/Lucette/Yiznell, Evra patch, Nuvaring) You must enter a Blood pressure reading – we will not be able to process this form and book an appointment without one

Blood pressure reading *Recorded within past week

If you are not able to take a weight/height or BP measurement at home or at the pharmacy you can drop into the surgery between 8.30 and 6pm and use the pod.

For patients who have a coil or implant in place and would like it taken out/another one put in please give us details here:

When we have received this form we will contact you by text to give you an appointment to discuss your request. Would you prefer this appointment to be: *On the phoneFace to faceI don't mind

If we are satisfied we have all the information to safely prescribe your contraception we may be able to let you know by text and send the prescription straight to the pharmacy, would you be happy with this? *YesNo

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