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Home > Contraceptive Pill Request Form

Contraceptive Pill Request Form

Contraceptive Pill Request Form

**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**

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

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

Side Effects
For Office Use Only:

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

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The information below is for patients


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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.

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.


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The Atherstone Surgery

1 Ratcliffe Road, Atherstone, Warwickshire, CV9 1EU

  • 01827 713664
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