Requests for repeat prescriptions of contraceptives

Requests for starting and repeat prescriptions of oral contraception

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 nnicb-nn.cvamp@nhs.net or post it in our post box at the side of the surgery. Alternatively please complete the online submission below.

Warning advice: Note:

Please scroll further down if you are requesting the Combined Oral Contraceptive Pill

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

MM slash DD slash YYYY
Is this a repeat medication request?
If you are requesting a new medication please make an appointment to see your GP
Your smoking status:
A scale is available in the reception area
A height measuring station is available in reception area
MM slash DD slash YYYY
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 nnicb-nn.cvamp@nhs.net 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 oral contraceptive pill

MM slash DD slash YYYY
Is this a repeat medication request?
If you are requesting a new medication please make an appointment to see your GP
Do you have migraine or any headaches?
If you have migraines, your GP may need to discuss this further with you
Do you have or does your family have a history of blood clots e.g. DVT?
If you have blood clots your GP may need to discuss this further with you
Does your family have a history of breast cancer?
If there is a new diagnosis of breast cancer in your family, your GP will need to discuss this further with you
Your smoking status:
A scale is available in the reception area
A height measuring station is available in reception area
Please use the blood pressure machine in the reception area and write down the top and bottom numbers (e.g. 130/80)
MM slash DD slash YYYY
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