Llantwit Major & Coastal Vale Medical Practice

Contraception Pill Rapid Repeat

Rapid Repeat Request Form

Please only use this form if you are female and are currently taking the contraceptive pill.

(This includes social smoking)
(A migraine is a headache during which you can feel sick, have to lie down or can't look at lights)
(An Aura is a visual or sensory symptom in the hour before the headache starts)
If yes, please specify:
(This includes herbal supplements, over the counter medicines and medicines prescribed by a Doctor)
Frequently missed pills put you at risk of pregnancy. With typical use the pill is only 91% effective at preventing pregnancy. Consider switching method if your pill taking is poor
(We provide pills, implants, injections and coils)

If you are having unprotected sex you could be at risk of sexually transmitted infections. Please check our website for information about arranging a STI testing.

It is important you select as truthfully as possible so we can provide you with the correct advice and treatment.

Please now weigh yourself

WE REQUIRE YOUR BP FOR THIS PREOCESS. IF YOU HAVE NO ACCESS TO A BP MACHINE PLEASE CALL THE SURGERY AS WE MAY BE ABLE TO LOAN YOU ONE.
PLEASE DO NOT COMPLETE THIS FORM WITHOUT A BP AS WE CANNOT COMPLETE YOUR REQUEST WITHOUT IT

All fields marked (*) on this form are mandatory, please complete to the best of your knowledge. By using this form, you will be sending information about yourself across the Internet. 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 to notify us of your details.

Please allow 48 hours for your prescription request to be issued and allow the pharmacy time to dispense this for you. If we wish to discuss anything further; you may be contacted at some point, please ensure the mobile number you have provided is correct. By submitting this form you understand and accept these conditions.

 

During COVID-19 

Please be aware our Coil Clinic Service has been dispended during this time.

We thank you for your co-operation. 

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