Contraceptive pill repeat request
In order to make sure that is safe for you to take the PILL the surgery requires update our records with your latest information

*** Your GP may ask you for your latest weight and Blood pressure (BP). If your do not have this the surgery may ask you to collect your medication from reception

Your Details
Your Full Name *
Your answer
Your Date of Birth *
Please include your DOB in the form of dd/mm/yyyy i.e 01/01/1980
Your answer
Phone number *
If we need to contact you to clarify your answers
Your answer
E-mail *
If we need to contact you to clarify your answers
Your answer
What is the full name of the PILL you would like to request? *
Please enter full name of the pill you are taking e.g. Microgynon, Mavelon, Mercilon, Cilest, Cilique, Rigevidon, logynon, Yasmin, Dretine, Qlaira, Femodene, Femodette
Your answer
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