Contraceptive Pill Prescription Request




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Personal Details
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Your Health

Blood Pressure

You can check your blood pressure at a local pharmacy or use the machine in reception

Your systolic blood pressure is the top number on your reading
Your diastolic blood pressure is the bottom number on your reading

Weight & Height

There are scales available in the waiting area of the surgery

Please use kgs
Please use Metric Measurements


If you can't remember the exact day please enter 01 for the day

If the above results are judged to be unsafe for continuation of the medication, you will be asked to see a practice nurse.


I understand that the contraceptive pill has certain risks associated with its use, as outlined in the patient leaflet previously provided with my pills, and that smoking increases these risks. The information provided is correct to the best of my knowledge.

A leaflet will be provided with you prescription that discusses long acting contraceptive options, please contact the medical centre and ask for an appointment if you wish to discuss this further.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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