Are you pregnant or breastfeeding?

Do you have any problems with your liver or kidneys?

Have you been taking your current pill for a year or more?

Are you up-to-date with cervical smears?

• Smears are usually needed 3 yearly for women 25-49 years and 5 yearly from 50-64 years.
• Smears may be needed more frequently if there has been a previous abnormal smear.

Are you experiencing problems with your current pill, particularly unexplained or irregular bleeding?

Have you been diagnosed with any of the following?

• Diabetes or migraine
• High blood pressure, heart attack, angina, abnormal heart rhythm, impaired heart function
• Breast cancer or family or genetic risk of breast cancer
• HIV or liver disease

Are you experiencing problems with your current pill, particularly unexplained or irregular bleeding?

Are you taking any of the following medication?

Carbamazepine, griseofulvin, modafinil, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John’s Wort, topiramate, and, above all, rifabutin and rifampicin.

Have you ever been told by a doctor or specialist that you shouldn’t use hormonal contraception?

Was your last period abnormal for you and your usual cycle?

Are you over weight?

Use the link on the NHS website below and answer yes if it is over 35

https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

Are you a smoker and 35 and over?

Have you had thrombosis (blood clots) or does thrombosis run in your family?

Are you having any issues with your current pill?

Have you had surgery in the last year or are you immobile, for example wheelchair or bed bound?

Do you have a personal or family history of the following conditions?

• Breast, ovarian, cervical or uterine cancer
• Bleeding disorder such as blood clots
• Epilepsy
• Endometriosis
• Varicose veins
• High blood pressure
• Gallbladder or liver disease
• High levels of fat in the blood
• Unexplained vaginal bleeding
• Systemic Lupus Erythematosus
• Porphyria

Have you been advised by a doctor or nurse to have special monitoring of your contraception?

Are you aware the hormones in contraceptive pills can cause depression?

This can be a risk factor for suicide (rare).

Do you have any medical conditions?

Do you have any further medical information or questions?

Is there anything you do not understand or do you need further help?

Please note. You can ask questions at any time using our live chat feature, email or giving us a call.

Do you have any concerns about your safety or well-being?

Answer ‘Yes’ if you feel vulnerable, or you are being forced to obtain treatment.

Do you agree to the following?

• You will read the Patient Information Leaflet supplied with your medication.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment.
• The treatment is solely for your own use.
• You are over the age of 18 and you have entered your own information for our identity verification checks.
• You have answered all the above questions accurately and truthfully.
• You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You will inform your own GP of this purchase if appropriate.
• You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions.

What is the name of your GP surgery and do you consent to us contacting them about your treatment?