Repeat prescription for progestogen-only pill (POP)

Please complete and email the form to buc-tr.bhtbshaw@nhs.net. This form will allow a clinician to re-issue your prescription if safe to without you having to come in for an appointment. If you have any questions please ring 0300 303 2880. Completion of this form does not guarantee that we will be able to issue your repeat prescription and we may need to ring you to discuss further.
PERSONAL DETAILS
Full Name Click or tap here to enter text.	Date of birth Click or tap to enter a date.
Address Click or tap here to enter text.	Mobile number Click or tap here to enter text.
Click or tap here to enter text.	Home number Click or tap here to enter text.
Postcode Click or tap here to enter text.	E-mail address Click or tap here to enter text.
ABOUT YOUR PILL
What is the name of your progestogen-only pill?
Have you had any problems or concerns with your pill?	Yes ☐ Yes ☐ No
Have you been on this pill for more than a year?	Yes ☐ Yes ☐ No
Any missed or late pills?	Yes ☐ Yes ☐ No
Are you experiencing any unwanted side effects?	Yes ☐ Yes ☐ No
Have you had any irregular bleeding?	Yes ☐ Yes ☐ No
Please confirm that you have no new concerns about this pill (if you have any concerns please ring 0300 303 2880 to discuss)	No ☐ No ☐ concerns I have concerns
I confirm that I know what to do if I miss a pill	Yes ☐ Yes ☐ No
MEDICAL HISTORY
If you answer yes to any of the following questions, we may contact you to discuss further.
Have you started any new medication since your last pill prescription? If yes, please list: Click or tap here to enter text.	Yes ☐ Yes ☐ No
Have you been diagnosed with any new health conditions since your last pill prescription? If yes, please list: Click or tap here to enter text.	Yes ☐ Yes ☐ No
Do you have breast cancer?	Yes ☐ Yes ☐ No

Remember that the progestogen-only pill does NOT protect against sexually transmitted infections (STIs), so you may need to use condoms as well. If you have had a new sexual partner since your last pill prescription, or have any symptoms, we recommend that you have a full STI screen. Please ring 0300 303 2880 to book. There are long acting methods of contraception available https://tinyurl.com/bshaw-larc, if you would like to discuss further please ring 0300 303 2880. If you have concerns about your progestogen-only pill at any time, please ring 0300 303 2880. Further information on the progestogen-only pill: https://tinyurl.com/bshaw-pop

Please confirm how you would like to receive your prescription or pills: (please tick only one option) ☐ I would like to receive a prescription for my pill in the post. We can only issue a maximum of six months’ supply at a time. A text message will be sent once your prescription is posted. Please allow up to 10 working days to receive your prescription once it has been posted. The address of the clinic will be stamped on the back of the envelope. ☐ I would like to collect the pills from clinic. Please do not attend clinic without an appointment. We will contact you to arrange a time to collect your pills.
I I confirm that the information provided is accurate to the best of my knowledge
Signature of patient: Click or tap here to enter text.	Date: Click or tap to enter a date.