0 Request for Ongoing Contraception * Denotes required fieldsPersonal DetailsName* Email* Date of Birth* - some browsers require the date in the following format: YYYY-MM-DD format (e.g. 2013-04-08) Daytime Telephone* Name of Pill Required* Any Concerns with the pill?* Please note, the practice can only issue a one month supply if the following information is not supplied:Weight?* BP?* Please use this form ONLY if you have recently received a short supply of your medication (<3m).It will be reviewed by a GP/Advanced Nurse Practitioner who will then contact you.