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Repeat Contraception Prescription  Form

Oral contraception prescription form

Personal Information

Date
Day
Month
Year
Birthday
Day
Month
Year
Multi-line address

Medical information

Medical History VTE ot thrombophilia?(blood clot)
Yes
No
Do you smoke?
Yes
No
Medical History Ischemic heart disease or stroke?
Yes
No
Do you have high blood pressure?
Yes
No
Have you recently childbirth?
Yes
No
Are you breastfeeding?
Yes
No
Do you have migraine?
Yes
No
Do you have personal history of breast cancer?
Yes
No
Do you have family history of breast cancer-related gene mutation?
Yes
No
Blood pressure measure in the past 2 week?
Yes
No

Pharmacy details

Pharmacy details

In order to provide your care we need to collect sensible personal and medical information. We recognise the importance of protecting data personal medical records in all that we do, and take care to meet our legal and other duties, including compliance with relevant law, Medical Council regulations and guidance. Under the General Data Protection Regulation (GDPR) Central Park Medical is obliged to ensure patient data, supplied as part of the patient process.

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