Progesterone Only Contraceptive Pill

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Personal Details
Please double check you've entered the correct email address
May be used to identify you
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Name of pill requested: *

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.

Please provide a blood pressure reading taken within the previous month (systolic/diastolic e.g. 125/75). You can get your blood pressure checked at a pharmacy or book an appointment with the healthcare assistant

Upper Reading
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Do you have or have you ever had breast cancer?: *
Have you ever been diagnosed with heart problems or stroke?: *
Have you ever been diagnosed with a liver problem?: *
Are you taking any over-the counter medication that we are not aware of?: *
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Declaration

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Care Quality Commission
Rating: Good

Clapham Park Group Practice
72 Clarence Avenue
London
SW4 8JP

Telephone: 020 8678 5420

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