Requesting Your Oral Contraceptive Pill - Wandsworth Medical Centre

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:

YourselfSomeone else

About you

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

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

Postcode*
The one used to register with your GP.

Your Date of Birth*
Your date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on your medical record.

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

Email*
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

First Name*
As it appears on the patient's passport

Last Name*
As it appears on the patient's passport

Postcode*
The one registered with the patient's GP

Your Date of Birth*
Patient's date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on the patient's medical record.

About you

First Name*

Last Name*

Your Date of Birth*
Your date of birth is used to verify your identity

Sex*
MaleFemaleOther
As on your medical record.

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

Please continue completing the form below

Address (including postcode):

Contraception Pill Review

Name of medication requested*

Is this a repeat medication request?*
YESNO

Are you having any side effects?*
YESNO

Do you suffer from severe headaches or migraines?
YES - But the doctor is unawareYES - But the doctor is unawareNO

Do you have a history of blood clots?*
YESNO

Do you have a family history of breast cancer?*
YESNO

Do you smoke?*
YESNO

What is your weight*
A scale is available in the reception area

What is your height*
A height measuring station is available in the reception area

Blood pressure reading:*
Please use the blood pressure machine in the reception area or visit a local pharmacy

Date blood pressure taken:*

When was your last cervical smear test?*
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.

Confirmation
I confirm that the information provided is accurate to the best of my knowledge

Please upload any documentation that might be relevant to your request:

(File types accepted .png, .jpg and .pdf. Maximum file size 5mb)

Monday	08:00-18:30
Tuesday	08:00-20:00
Wednesday	08:00-20:00
Thursday	08:00-18:30
Friday	08:00-18:30
Saturday	09:00-13:00/16:00*subject to availability
Sunday	Closed

Oral contraceptive pill

Oral contraceptive pill request form

Contraception Pill Review

Opening Hours