Progesterone Only Pill Review

First Name: *

Surname: *

Date of Birth: *

Age *

Contact Number: *

Which pharmacy would you like your prescription sent to? *

Are you planning a pregnancy in the next 12 months? *

Yes

Unsure

Height:

Weight:

Do you Smoke? *

Yes

No - Never Smoked

No- Ex Smoker

Is your cervical smear up to date? *

Yes

Unsure

Pill-Related Questions

Please tick this box if you consent to us storing the data provided in this form, and consent to us contacting you if necessary. *

I consent

Feedback

Here at Bangholm, we are always looking at ways to improve our patients access and experience.

This form has been created as part of our improvement project for 2023/24.

If you have any feedback for us, please do let us know!

Thank you

How useful did you find submitting this form, instead of waiting for an appointment? *

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