Requesting A Repeat Combined Oral Contraceptive Prescription

Last Updated: 04/09/2024

  • Request Repeat Combined Oral Contraceptive Pill

    • Please complete this form to request a repeat prescription of your combined (oestrogen and progesterone) oral contraceptive pill e.g. Rigevidon (same pill as Microgynon 30), Cilest, Marvelon
    • A doctor might need to speak to you prior to issuing the prescription
    • Information on how to take your combined contraceptive pill can be found here
    • Information on the different contraceptive methods available in the UK is available here
    • Information on having an implant or coil fitted or removed can be found here
    Date of Birth
    For example, 15 3 1984
    Name of Combined Oral Contraceptive Pill requested

  • Nominated Pharmacy

    Nominate a pharmacy of your choice and this pharmacy will receive your prescription directly from your GP, via the Electronic Prescription Service (EPS). With EPS you will not have to visit your practice to pick up your paper prescription anymore. (Click here for more details)

  • Health Details

    Use the link if you need help calculating the number of alcohol units you consume per week - Unit Calculator
    When was this reading taken?
    For example, 15 3 1984
    What is your smoking status

  • Health details - continued

    If you answer ‘Yes’ to any of the following questions, do not continue with this form, or submit it, and book an urgent appointment with a clinician to discuss the suitability of this pill for you

    Have you ever had breast cancer, OR do you have any undiagnosed breast symptoms, OR are you known to have any breast gene mutation (e.g. BRCA1)?
    Have you ever had a blood clot in your legs or lungs (deep vein thrombosis or pulmonary embolism) OR are you known to have a blood clotting mutation (e.g factor V leidin, prothrombin mutation, protein C or S, antithrombin deficiencies)?
    Have you ever been diagnosed with diabetes, high blood pressure, heart problems, stroke or high cholesterol?
    Have you ever been diagnosed with a liver or gallbladder problem?
    Have you ever been diagnosed with systemic lupus erythematosis (SLE) or with antiphospholipid antibodies?
    Have you ever had a headache or migraine associated with visual disturbance, flashing lights, loss of vision, temporary numbness, paralysis or difficulty with speech?
    Do you have any problems with your mobility (e.g. wheelchair, debilitating illness)?
    Are you due to have any major surgery or have you had any major surgery in the previous 3 months?
    Have you had a baby in the previous 6 weeks?
    Have any of your first-degree relatives had a blood clot in the legs or lungs (deep vein thrombosis or pulmonary embolism)?
    Are you taking any prescribed or over-the counter medication?

  • IMPORTANT NOTICE

    A reminder that if you have answered "Yes" to any of the previous questions do not proceed any further with this form, or submit it, and book an appointment with a clinician to discuss the suitability of this medication

  • Declaration

    I confirm that this is a repeat prescription request
    I confirm that I am aware of how to take my pill
    I confirm that I am aware of different contraceptive methods and opt to use the combined oral contraceptive pill
    I confirm that any medication prescribed for me is for my personal use only and that I have responded honestly and provided complete and accurate information
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