Pill Prescription Request

Free Contraception Pill Prescription Form

Please allow 48 hours for the prescription to be sent to your pharmacy.

First name

Last name

Date of Birth (dd/mm/yyyy)

Phone

Full Address

Medications (include name of medication, dose, duration)

Usual GP

Nominated Pharmacy

I consent to my prescription being digitally sent from the practice to my chosen pharmacy.

I acknowledge that it takes up to 48 hours (excluding weekends) to process prescriptions requests.

I consent to this message being sent electronically to the practice. I have checked that the email address and phone number supplied are corretct and consent to receiving medical information via email or text.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

Free Contraception Pill Prescription Form

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