On-line version 3.1 printed on 06/02/2016
ETTINGSHALL MEDICAL CENTRE
Contraceptive Pill Repeat Prescription Request Form
You may apply for a repeat prescription of the same contraceptive pill if:
•you are aged between 18 and 35
•you are currently taking a contraceptive pill that has been prescribed by a GP or nurse at our practice
PLEASE WRITE THE NAME OF THE PILL YOU ARE TAKING 
For your safety, to apply for a repeat prescription:
You must have had your blood pressure and weight measured in the last year, please use the selfmonitoring machine in the waiting room and attach to this form. If your weight or blood pressure is outside
certain limits you will need to see a nurse
You must have had a cervical smear test within the last three years if you are aged 25 or over.
If any of the following statements are true for you then do not use this form; make an appointment to see the
nurse
• problem with your general health or any changes to your medical history in the last 12 months
• problem with using your contraceptive pill or side effects from the pill i.e. migraine
• any health matters you wish to discuss with your GP or practice nurse
We recommend that you consider using long acting reversible contraception such as the coil or
implants. Please see the nurse or doctor to discuss this further; alternatively you could request
printed information from reception.
To request a repeat prescription, please answer all the questions by ticking the
relevant box, print & sign the signature box and hand the form in at the reception
Do you have:
Yes
Any problems with your general health
Any problems with using your contraceptive pill or side effects from the pill
Any health matters you wish to discuss with your GP or Practice Sister
Migraine headaches, severe headaches or frequent headaches
Bleeding between periods
Bleeding during or after sexual intercourse
Unusual discharge
Depression or depressed mood
History of thrombosis (blood clots in veins or lungs) or family history of clot
□
□
□
□
□
□
□
□
□
No
□
□
□
□
□
□
□
□
□
If the answer to any of the questions is YES please make an appointment with the Practice Sister.
The final step – tick one of the following statements
□
I have checked my blood pressure and weight using the self-checking machine in the waiting room and have
attached the printout
□
I have had my blood pressure checked at the practice in the last 3 months. My height is _____ centimetres and
my current weight is _____ kilograms
Declaration: I understand that the contraceptive pill has certain risks attached to it as outlined in the patient
leaflet previously provided with my pills and that smoking increases these risks.
Name
Address:
Contact telephone number:
*Signature (required)
Date of Birth
Today’s Date:
1
On-line version 3.1 printed on 06/02/2016
Please hand the form in at reception to be checked.
Enclose a stamped addressed envelope if you wish your prescription to be posted to you. However, please be
aware that if your completed form is not checked by the reception team we may require you to come to the
surgery for various checks, resulting in a delay to your prescription. Please allow two working days for your repeat
prescription to be ready.
Practice Use Only
Seen by clinician in surgery in the last 12 months( if not must see
Date
nurse)
Age Checked
BMI (if over 30 must see nurse)
BP (if top number over 140 OR bottom number over 90 must see nurse)
Smear (age 25+)
Prescription issued for 6/12 –
Pills issued:
leaflet enclosed Yes □ No □
Initials
2