Contraceptive Pill Request

Please fill in the form below to place an order for your contaception pill, If a review is needed on your contraception them a member of the prescription team will be in touch.

Last Updated: 01/05/2024

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Blood pressure (This can be done by popping in to one of our practices to do this on the reception machine or alternatively if you have a blood pressure machine at home) *

Contraceptive Pill Details

What is the name of your contraceptive pill? *

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

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Contraceptive Pill Request

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