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LOCKSIDE MEDICAL CENTRE

85 Huddersfield Road, Stalybridge SK15 2PT

Telephone: 0161 303 7200

Sorry, we're currently closed. Please call NHS 111 or for minor ailments please visit a local pharmacy.

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Please provide the Name & DOB of ANY members of your household that have moved to the same address.*

ONLY REQUIRED IF YOU ARE PROVIDING A CHANGE OF ADDRESS and family members are currently registered with us. Please note 'NA' if this is not applicable to you.

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Name*
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What is the name of your contraceptive?*
What is your weight?*
What is your height?*
Do you smoke?*
If you do smoke how may cigarettes do you smoke, on average, each day?
If you smoke, would you like support to stop?*
Smoking increases your risk of heart disease and stroke, as do some hormone therapies and so we advise you stop smoking whilst on this medication.
What is your blood pressure?*
Please take a reading today (either by a home BP device or by using the machine in our waiting room). Readings should include both numbers. If you need help taking a home reading please click on the link below.
http://www.bloodpressureuk.org/your-blood-pressure/how-to-lower-your-blood-pressure/monitoring-your-blood-pressure-at-home/how-to-measure-your-blood-pressure-at-home/
Have you, or a close relative, ever had a blood clot (DVT or pulmonary embolism)?*
Have you ever had a migraine with 'aura'?*
If you are unsure what an 'aura' is, please click on the link below.
https://www.nhs.uk/conditions/migraine/symptoms/
If you have any problems with your contraceptive please let us know here.
Patients like to know about the risks and benefits of their treatments. Please visit the NHS website for up to date information on contraception choices.
https://www.nhs.uk/conditions/contraception/ Please be aware that if you are currently using a medication called GLP1 agonist (for diabetes or weight loss, for example ozempic, mounjaro or similar), this can affect the absorption of oral contraceptive pills. If you are using this medication please consider an alternative method of contraception. www.contraceptionchoices.org
I have been directed to information about risks and benefits of contraceptives and am happy to continue using my current contraceptive.*
- I am happy to proceed