Request for period delay using Provera

Use this service to request for a delayed period using Provera.

This form should be submitted at least two weeks before the required date to allow time for review and prescription processing.

You can use this service if you:

• are registered at the surgery

Before you start

We’ll ask you for:

• your first and last name, date of birth, sex, postcode, email and phone number
• if applicable, the details of the person you are completing the form on behalf of

Start now

You can also phone us on 01384 254423.