Requests for repeat prescriptions of contraceptives

As well as providing emergency contraception pharmacists can now initiate and provide a repeat prescription for the Progesterone Only Pill (POP) and the Combined Oral Contraceptive Pill (COCP) in straight forward cases. If this is not possible please use the forms below.

Progesterone Only Pill (POP) contraceptive

Please download and complete this form if you are requesting a Progesterone Only Pill (POP) contraceptive and either email the form to [email protected] or post it in our post box at the side of the surgery. Alternatively please complete the online submission below.

Chilwell Valley and Meadows Practice form for requesting a repeat prescription for the progesterone only pill contraceptive

First name

Surname

Date of birth

Name of medication requested Optional

Is this a repeat medication request?

Yes Optional

No Optional

If you are requesting a new medication please make an appointment to see your GP

Are you having any side effects? Please list: Optional

Your smoking status:

Current smoker Optional

Ex-smoker Optional

Never smoked Optional

If you smoke, please state the number of cigarettes per day: Optional

Please enter a number from 0 to 100.

What is your weight (Kg)? Optional

A scale is available in the reception area

What is your height (Metres)? Optional

A height measuring station is available in reception area

When was your last cervical smear test? Optional

If you are over 25y you should have had a cervical smear test. If you have had a smear test, but it was more than 3 years ago please book an appointment for this with the practice nurse

Your doctor may need to contact you about certain details in this form

Combined Oral Contraceptive Pill

Please download and complete this form if you are requesting a Combined Oral Contraceptive (COC) pill and either email the form to [email protected] or post it in our post box at the side of the surgery. Alternatively please complete the online submission below.

Requests for starting and repeat prescriptions of oral contraception

Progesterone Only Pill (POP) contraceptive

Non-urgent advice: Note:

Chilwell Valley and Meadows Practice form for requesting a repeat prescription for the progesterone only pill contraceptive

Your doctor may need to contact you about certain details in this form

Combined Oral Contraceptive Pill

Chilwell Valley and Meadows Practice form for requesting a repeat prescription for the oral contraceptive pill

Your doctor may need to contact you about certain details in this form