Contraceptive Pill or Patch request form

Contraceptive Pill or Patch request form

Please only use this form if you are already established on contraception. 

If you wish to START contraception then please make an appointment. 

A clinician will review the information and issue a script within 48h of receipt. We will send it to your nominated pharmacy (if you have already made an arrangement with us.) Otherwise it will be left at reception for you to collect in person. If there is a problem then we will contact you on the number you have written above.

  • Your details

    This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
    Date of Birth
    For example, 15 3 1984

  • Please complete the following:

    I am happy with my contraception and do not have any side effects.
    Smoking Status
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Page last reviewed: 22 October 2025
Page created: 08 October 2025