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Contraception Request Form

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Contraceptive Pill Request

Please hand this questionnaire to reception with a weight and blood pressure reading taken within the last year.

We may still need to book you an appointment with the nurse if the readings are outside certain limits.

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All questions marked with a * are mandatory

Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Blood Pressure

If you do not have a machine at home, please come to reception and have your blood pressure and weight measured on the practice machine.

Higher number

Lower number

As your Blood Pressure is over 140/90 this needs to be reviewed

You cannot continue with this form: *

Body Mass Index

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This form collects personal and medical information about you and 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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Providing NHS Services

Rolle Medical Partnership
Exmouth Health Centre
Claremont Grove
Exmouth
EX8 2JF

Telephone: 01395 226540

Treetops Surgery
Prince of Wales Drive
Exmouth
EX8 4SW

Telephone: 01395 226540

Raleigh Surgery
33 Pines Road
Exmouth
EX8 5NH

Telephone: 01395 226540

Underhill Surgery
Lympstone
EX8 5HH

Telephone: 01395 265797