The Hadleigh Practice

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Contraceptive Pill Review

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Personal Details

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Your Health

Are you a smoker?:

Have you had any problems with your pill? : *

Do you suffer with migraines? : *

Is there any personal or family history of blood clots?: *

Have you had any other medical problems since your last prescription?: *

Important Information

Please read the following important Information

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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