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Contraceptive Injection Request Form

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Please select an option to continue: *

Please complete your details below and you will be added to the waiting list and the practice will contact you when an appointment is available

Please allow 2 working days notice for collection from reception, if you are collecting from a pharmacy please refer to their individual policy

Statements

Are you aware how the injection works?: *

Are you aware of the side effects and risks of using the injection?: *

Are you aware what to do if you are late (over 13 weeks) for your next injection: *

Are you aware that the contraceptive injection does NOT protect you from sexually transmitted infections. : *

So it is advisable to use condoms or get a STI screen with new partners

You have answered No to one or more of the questions above,

Please use the resources below to find out more information. If you are then still not confident enough to answer Yes to any of the questions above, please arrange an arrange an Accurx or telephone appointment

INFO ON RISKS, DRUG INTERACTIONS & SIDE EFFECTS

Contraception Injection Review

Do you have any problems with using your contraceptive injection or side effects: *

Do you have any health matters you wish to discuss with your GP or Practice Nurse: *

Do you have significant weight gain : *

Do you have change in you bleeding pattern : *

Do you have bleeding during or after sexual intercourse: *

Do you have unusual discharge: *

Do you have any family history of osteoporosis (thin bones): *

You have answered Yes to one or more of the monitored questions above, please arrange an Accurx or telephone appointment

Health Questions

Please indicate whether you have used feet, inches, metres or centimetres)

Please indicate whether you have used stones, pounds or kilogrammes

Personal Details

Please double check you've entered the correct email address

May be used to identify you

Which surgery are you registered with?: *

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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