Contraceptive Pill Review Form Whitley House Surgery

If you have been advised by the surgery to submit a contraceptive pill review please use this form.

You only need to complete this ONCE PER YEAR.

If it has been less than a year, you may have repeat medication on your clinical record you can request without needing to complete and submit this form. 

You will get one prescrition at the time of your review (usually for 6 months medication).

A second presciption will be added to your clinical record (usually for a further 6 months medication). You can request this 'repeat medication' using NHS App or by completing your repeat slip from your previous medication and handing it to reception. 


Last Updated: 02/11/2023

Your Details

Data Protection

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 our 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. 

Your Current Contraception and Periods

Your Medical History

Further Information

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