Contraceptive Pill Request Form

Title

First Name

Surname

Date of Birth

Address

Post code

Home Telephone

Mobile Number

Email Address

Name of current GP

Where would you like to collect your prescription from?

Name of current pill (if known)

**If you have already run out or have less than two pills left, you should make an urgent appointment for a pill check instead of using this form**

Weight (In stone & lbs OR kg please specify which is used)

Smoking

Are you a smoker?

If you are currently a smoker and would like to stop please contact the surgery to discuss this further.

Side Effects

Are you experiencing any problems with your pill?

Have you had any problems with forgetting to take your pill?

Have you had your blood pressure checked win the last 12 months?

If you are over 25, have you had a smear test in the last 3 years?

Have you been given information about implants &/or coils?

Please tick below to acknowledge that all information provided is accurate to the best of your knowledge

For Office Use Only:

If you are a patient please do not complete the following questions

Last contraceptive review appt

Last BP reading

Date

Name of pill (if not completed above)

Doctors decision

Patient Confirmation

The information below is for patients

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Atherstone Surgery • 1 Ratcliffe Road, Atherstone, Warwickshire, CV9 1EU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.