Contraception Request Form
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Select the Blood Type
Please Select
AB RH +
A RH +
B RH +
0 RH +
AB RH -
A RH -
B RH -
0 RH -
Patient Height (cm)
Patient Weight (kg)
What kind of birth control medicals do you use?
Do you smoke?
Yes
No
Any problems with contraception or side effects from it?
Yes
No
If yes, please describe it.
Do you have any new/unusual bleeding?
Yes
No
Although the general risk of a blood clot as a result of taking the pill is low, it can be a major risk for some women.
Smoking, traveling on a long-haul trip (more than 3 hours), trekking at an altitude greater than 2500m, having recently had an operation, or being bed-bound for an extended period all enhance your risk.
Signature
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