Free Contraception (17-35 years) repeat prescription request Please allow 5 working days for the prescription to be sent to your pharmacy. Name * First Name Last Name Date of Birth (DD/MM/YYYY) * Phone * (###) ### #### Medications * Nominated Pharmacy * Checkbox I ACKNOWLEDGE THAT IT TAKES UP TO 5 WORKING DAYS (EXCLUDING WEEKENDS) TO PROCESS REPEAT PRESCRIPTION REQUEST I acknowledge that this form is for free contraception only, and that any other medication requests will incur a fee Your request has been successfully submitted.
