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Riverside Surgery

Primary Care Resource Centre, Moor Road, Port Talbot, West Glamorgan, SA12 7BJ

01639 813868

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Contraception / HRT Medication Request Form

Contraception / HRT Medication Request Form

We have created this form to improve patient convenience and access to contraceptive or HRT medication. Please complete it in full for review by the clinical team.

Name

Date Of Birth

Telephone Number

Email Address

Contraceptive or HRT being requested:

Contraceptive
HRT

Your Weight

Your Height

BMI (Body Mass Index)

Smoking Status

Smoker
Never Smoked
Ex-Smoker

Do you have a history of any of the following: (please tick if yes)

Migraines
Blood Clots
Stroke
Breast or Ovarian Cancer
Recent change in your period pattern

Have you had any gaps or breaks in taking your contraceptive/ HRT medication?

Yes

No

Have you accidently missed any contraceptive pills since your last period?

Yes

No

Is there a chance you could be pregnant?

Yes

No

Are you overdue your next smear test?

Yes

No

Do you have any specific concerns, queries or comments to add?

Thank you. Your message has been sent to your surgery.

Sorry, something went wrong. Please try again.

Riverside Surgery

Primary Care Resource Centre
Moor Road
Port Talbot
West Glamorgan
SA12 7BJ

01639 813868

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