This form is for women already established on a contraceptive pill.
Please complete the form as fully as possible. This is to ensure patient safety. We are unable to process prescription requests without an up to date height, weight or blood pressure. Once your form has been processed, a prescription will be issued for 12 months supply of your medication – please ensure you collect the total balance from the pharmacy.
Please read information on blood clots.
If a prescription is not issued we will contact you to let you know.
