Oral contraceptive pill

If you’re up to date with your pill check (every 6/12 months), you can request a repeat of your contraceptive pill without a doctor’s appointment. Please complete and submit the oral contraceptive pill form and collect the prescription form the nominated pharmacy in the two working days.

If you’re not sure when your last pill check was, please ask at reception.

Please note that we only accept forms with details of your blood pressure reading done in the last 12 months.

Please visit the surgery or your local pharmacy to have the blood pressure reading done or contact the reception team for details of your last blood pressure reading.

Oral contraceptive pill request form

    Required fields are indicated by *

    Are you completing this form on behalf of:

    About you


    Name(s) as it appears on the patient's passport.


    Name(s) as it appears on the patient's passport.


    The one used to register with your GP.


    Your date of birth is used to verify your identity



    As on your medical record.


    This phone number will be used for all correspondence relating to this request.


    This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

    About the patient


    As it appears on the patient's passport


    As it appears on the patient's passport


    The one registered with the patient's GP


    Patient's date of birth is used to verify your identity



    As on the patient's medical record.

    About you




    Your date of birth is used to verify your identity



    As on your medical record.


    This phone number will be used for all correspondence relating to this request.


    This email address will be used for all correspondence relating to this request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

    Please continue completing the form below


    Contraception Pill Review









    A scale is available in the reception area


    A height measuring station is available in the reception area


    Please use the blood pressure machine in the reception area or visit a local pharmacy



    If you are over age 25 you should have had a cervical smear test. If you have had a smear test, but it was more than 3 years ago, please book an appointment with the practice nurse for a repeat test.


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