Order Form

These online services are restricted by your postcode of residence; if your postcode is not accepted, or you are having difficulty ordering your kit, please call our telephone service on 01483 675389 (Surrey).

Contraception and sexual infection testing & management
Please click below for specific details:
London services Surrey services
Surrey services
Please click a service below or for information about other Surrey services please click here.

London services
Please click a service below or for information about other London services please click here.

A sexual health screen for home delivery Contraception
Online Contraception
Surrey residents who are aged 18 or over can request some contraceptives online; these are:
- Progestogen-only pill (POP).
- Combined Hormonal Contraception: available if you are a current user of this method and have already received this from our service within the last 12 months.
  If you wish to start a CHC method then please call 01483 675389 (Surrey) or 0203 3175252 (London).
  This includes:
  Combined Oral Contraceptive Pill (COC)
  Combined Transdermal Patch (EVRA)
  Combined Vaginal Ring
We will ask you a number of health related questions to assess your suitability for this service as would happen in a clinic appointment.

For Combined Hormonal Contraception (COC pill, EVRA patch, vaginal ring) you will need to provide your current weight and blood pressure (BP) that have been measured within the last one month. Everybody’s BP is different and it can change (become high or low) without you noticing. Combined hormonal methods of contraception can increase one’s BP in a small percentage of women. High BP increases the risk of heart attack and stroke. It is therefore important that you provide us with a BP measured within the last one month so that we can ensure that it remains within the acceptable range. You can measure your BP at many places such as your GP practice, gyms and pharmacists. You can also buy BP monitoring devices from pharmacies and online. Have these measurements ready before you start completing the form for these methods.

Your answers will be reviewed by a clinician. Sometimes the clinician might need to call you to clarify the information you have provided, this will usually be within 5 working days of your request.

Medication or a prescription will be sent by post and may require a signature.

This will be issued on the understanding it is for your use only and for contraceptive purposes.

Please note there is no prescription charge for contraception.

We will let you know by text if we are not able to prescribe contraception online and you will be advised to make a phone consultation instead.
Are you 18 or over? Yes No
Are you 16/17? Yes No
Home self-test kits are available for Chlamydia, Gonorrhoea, HIV and Syphilis.
Your test today may not cover recent risks as it takes time for infections to develop. This is called the incubation period.

The incubation periods are:
- Chlamydia and Gonorrhoea: 2 weeks after risk
- HIV: 6 weeks after risk
- Syphilis: up to 3 months after risk
If you have any concerns, please re-test.

Your results give no indication of your partner's sexual health. You should encourage your partner to test too.

We will post your kit to you. You take your own samples and send it back. You’ll get your results by text or we will call you.

We can only offer home self-test kits to people who live within the Surrey County Council area.

Please enter your post code so we can check if you are eligible for this service.
Gender identity - Which of the following options best describes how you think of yourself? Female (including trans woman) Male (including trans man)
Non-binary In another way Prefer not to say
Is your gender identity the same as the sex you were assigned at birth? Yes No Prefer not to say
What type of kit do you need?
We need you to provide a genital sample to test for chlamydia and gonorrhoea.

What type of sample do you need?
Swab (for vagina/front hole) Urine (for penis)
If you have vaginal/front hole sex, then we recommend a vaginal swab. If you do not have a vagina or vaginal/front hole sex then we recommend a urine sample.
Who do you have sex with?
We use this to work out which test kit to send you
Women only Men and/or women and/or trans/non-binary
Are you a sex worker or do you engage in sex parties/group sex? Yes No
You may need additional swabs for your chlamydia/gonorrhoea test if you engage in oral or anal sex.
Do you require a throat swab? Yes No
Do you require a rectal swab? Yes No
We can test your blood for HIV and Syphilis using a finger prick test.
If you have not had an HIV test before, we recommend you have one. We also recommend regular testing for people who are at higher risk.

If you are not sure whether you need an HIV or Syphilis test or you want more information about HIV testing, visit this page.

You can do this now because you will be able to come back to this form once you’ve read the information.

Please note the HIV and syphilis tests are combined, with both done from the same sample at the laboratory. This means that if you are HIV positive and require a syphilis test you will also automatically receive an HIV test from the blood sample. As such, we will call you to inform you of the HIV+ result. We apologise for any inconvenience caused by this.
Do you want a finger prick test for HIV and Syphilis? Yes No
Have you ever been diagnosed and treated for syphilis? Yes No
Have you ever had a syphilis blood test in one of our clinics (Woking, Buryfields, Earnsdale)? Yes No
Have any of your sexual partners been five or more years older than you? Yes No
Have you ever been made to feel scared or uncomfortable by someone you have been having sex with or someone at home? Yes No
Domestic abuse / violence

Domestic abuse can be controlling, coercive, threatening behaviour, violence and abuse. This can be from a current or ex-partner or from a family member.

Domestic abuse includes physical violence (like hitting, kicking or slapping), emotional abuse (like calling you names or making you feel guilty), sexual abuse (like forcing you to have sex), financial abuse (like controlling your money), controlling/coercive behaviour (like controlling who you see or what you do), stalking and harassment (following you in person or with an app). It also includes honour-based violence (punished for bringing shame on the family), forced marriage and female genital mutilation.

Abuse like this can affect anyone, of any age, gender, religion, sexuality or ethnicity. Unfortunately, it is common, affecting 1 in 4 women, and 1 in 6 men.

It can be hard to know the difference between a ‘difficult’ relationship or an abusive one. If you feel scared, intimidated, controlled or unable to talk to anyone about what you are experiencing, that’s abuse.

If you are experiencing abuse, it is not your fault and it is not acceptable. You have the right to feel safe, live without fear and be supported and protected.

We know telling someone can be hard but there is help available using the links below. The police are specially trained to respond effectively to survivors of domestic abuse. It is important to seek support and help.

If you are in danger call 999 and if you can’t speak then press 55 – the police will attend your location as an emergency

The National Domestic Abuse 24h Helpline
freephone 0808 2000 247
www.nationaldahelpline.org.uk/Contact-us

Childline - the UK’s free and confidential service is not just for children, it provides help for young people of all ages who are in distress or danger. Counsellors provide advice and support, by phone, email and message board 24 hours a day.
Call: 0800 1111
www.childline.org.uk

The Hideout - Women’s Aid’s specialist support website for young people living with domestic abuse.
Email: Hideoutmoderator@womensaid.org.uk
Website: www.thehideout.org.uk (with a message board)

Have you been made to do something sexual that you didn’t want to do, or felt you could not say no to sex? Yes No
What is sexual abuse?

Sexual abuse is when a person is forced, pressured or tricked into taking part in any kind of sexual activity with another person. It can happen to women and men. The abuser can be a stranger, a friend, someone you are in a relationship with, someone you trust or a family member.

Sexual abuse isn’t just sex, it can be kissing, touching, oral sex or anything else sexual. There are also other forms of abuse that are similar to sexual abuse that involve nothing physical, like making you send pictures or sharing pictures you’ve sent. You can also get support for this.

If you are in danger call 999 and if you can’t speak then press 55 – the police will attend your location as an emergency

The Solace Centre (Sexual assault referral centre) in Cobham offers free support and practical help to anyone in Surrey who has experienced sexual violence and/or sexual abuse.
24 hour freephone: 0300 130 3038 email: surrey.sarc@nhs.net

Childline - the UK’s free and confidential service is not just for children, it provides help for young people of all ages who are in distress or danger. Counsellors provide advice and support, by phone, email and message board 24 hours a day.
Call: 0800 1111
www.childline.org.uk

Contact or walk-in to your nearest sexual health clinic, many of whom have access to independent sexual violence advocates and can refer you on to local support services. They can also offer you emergency contraception and screening for sexually transmitted infections.

Has anyone ever given you gifts, money, security, drugs or alcohol in exchange for sex? Yes No
Do you have a social worker? Yes No
Do you have concerns about your mental health? Yes No
If you use drugs or alcohol – does it worry you? Yes No
Do you meet your sexual partners online or through social media? Yes No
This online contraception form is for Surrey residents.
Please enter your postcode so we can check if you are eligible for this service.
Have you had an STI screen in the past year?
Everyone should get an STI screen including an HIV test at least once a year if they are having sex without a condom, or every time they change partners - even if they don’t have any symptoms.
Yes No
Surrey residents can now request STI tests online.

If you have no symptoms but want to check you don't have any sexually transmitted infections click here to order a home testing kit which also includes HIV and Syphilis (available to all over 18).

If you are under 25 years of age and have sex with the opposite gender only, you can order a quick access chlamydia/gonorrhoea urine test kit via the Chlamydia Screening Programme (CSP) click on this link. Please note this test does not include blood testing.
Type of Contraception
Please choose whether you would like a prescription for the progestogen-only pill (POP) or combined hormonal contraception (COC pill, EVRA patch or vaginal ring).
Progestogen-only pill
(POP) Combined Hormonal Contraception
(COC pill, EVRA patch, vaginal ring)
Are you currently taking the progestogen only pill? Yes, I want a repeat prescription of the Progestogen-only Pill No, I wish to start the Progestogen-only pill
The progestogen-only pill ('POP') is a small tablet that contains a progestogen hormone. It works by thickening the cervical mucous stopping the sperm meeting the egg and, in some women, it also stops ovulation.

Effectiveness: With perfect use only about 1 in 100 women will get pregnant each year. With typical use however about 9 in 100 women will get pregnant each year. This is because in typical use people forget pills or might do something else that makes it less effective. It becomes effective 48 hours after taking your first pill.

Advantages: Medically the POP is very safe, there are very few contraindications and risks. Whilst it is a good contraceptive for women of all ages, it is ideal for women who can’t take oestrogen or are older.

Disadvantages: You may not get a regular bleed with this method. Whilst some women may experience no bleeding others may experience bleeding at irregular intervals.

Use: The POP is taken daily, you do not take a break between packs. You should aim to take the POP at the same time each day. It is important not to take it more than 3 hours (12 hours for POPs with desogestrel) after your chosen time. We supply the POP with desogestrel to new customers.

Please read further information on the Progestogen-only Pill here.

We need to check that there is nothing in your medical history that might make it unsafe to use the POP

Online prescription of POP is offered only to women below the age of 55.
What is your current main method of contraception?

Please enter details.
Have you had sex without reliable contraception in the last three months? Yes No
Have you used emergency contraception in the last three months? Yes No
Do you think you might be pregnant? Yes No
Have you had any unexpected vaginal bleeding? Yes No
Are you taking any medication that you have been prescribed or bought? Yes No

Please enter details, name of the medication and the reason for taking it.
Are you taking St John’s wort? Yes No
Do you have any allergies (including peanut and soya allergies)? Yes No

Please enter details.
Have you ever had any of the following conditions:
- diabetes
- breast disease
- cancer of any type
- thrombosis/blood clot eg (DVT: Deep Vein Thrombosis or PE: Pulmonary Embolism)
- stroke (or TIA)
- heart disease
- liver disease or jaundice
- malabsorption syndromes
- gastrointestinal surgery
Yes No
Have you had any illnesses or operations (in the past or present)?
Please provide details, approximate dates and outcome: Yes No

Please enter details.
How many months' supply of pills do you want?
The progestogen-only pill ('POP') is a small tablet that contains a progestogen hormone. It works by thickening the cervical mucous stopping the sperm meeting the egg and, in some women, it also stops ovulation.

Effectiveness: With perfect use only about 1 in 100 women will get pregnant each year. With typical use however about 9 in 100 women will get pregnant each year. This is because in typical use people forget pills or might do something else that makes it less effective. It becomes effective 48 hours after taking your first pill.

Advantages: Medically the POP is very safe, there are very few contraindications and risks. Whilst it is a good contraceptive for women of all ages, it is ideal for women who can’t take oestrogen or are older.

Disadvantages: You may not get a regular bleed with this method. Whilst some women may experience no bleeding others may experience bleeding at irregular intervals.

Use: The POP is taken daily, you do not take a break between packs. You should aim to take the POP at the same time each day. It is important not to take it more than 3 hours (12 hours for POPs with desogestrel) after your chosen time.

Please read further information on the Progestogen-only Pill here.

We need to check that there is nothing in your medical history that might make it unsafe to use the POP

Online prescription of POP is offered only to women up to the age of 55.
What is the name of the POP you are taking?
Are you finding it difficult to remember to take the pills on time? Yes No
Have you been late or missed taking any pills in the last three months? Yes No
Have you used emergency contraception in the last three months? Yes No
Do you think you might be pregnant? Yes No
Have you had any unexpected vaginal bleeding? Yes No
Are you taking any medication that you have been prescribed or bought? Yes No

Please enter details, name of the medication and the reason for taking it.
Are you taking St John’s wort? Yes No
Do you have any allergies (including peanut and soya allergies)? Yes No

Please enter details.
Have you ever had any of the following conditions:
- diabetes
- breast disease
- cancer of any type
- thrombosis/blood clot eg (DVT: Deep Vein Thrombosis or PE: Pulmonary Embolism)
- stroke (or TIA)
- heart disease
- liver disease or jaundice
- malabsorption syndromes
- gastrointestinal surgery
Yes No
Have you had any illnesses or operations (in the past or present)?
Please provide details, approximate dates and outcome: Yes No

Please enter details.
How many months' supply of pills do you want?
In the last 12 months which CNWL service did you use for your Combined Hormonal Contraception?
Combined hormonal contraception is available online only to women who are currently receiving this method from either a CNWL sexual health clinic or CNWL online service. (We will check this against our records)
The combined oral contraceptive pill (also known as ‘COC’), the combined hormonal contraceptive patch (EVRA patches) and the combined hormonal vaginal ring contain a progestogen and an oestrogen hormone. They work by stopping you ovulating (producing an egg).

Effectiveness: With perfect use only about 1 in 100 women will get pregnant each year. With typical use however about 9 in 100 women will get pregnant each year. This is because in typical use people forget pills / patches / the ring or might do something else that makes it less effective. They become effective 7 days after starting the method.

Disadvantages: There is a very small increased risk of venous thrombosis and stroke when using these methods, the medical history you provide us with will assess whether you are at increased risk and therefore should not use an oestrogen containing contraceptive. Combined hormonal contraception increases the risk of heart attacks, breast cancer and cervical cancer.

Advantages: These methods give very predictable bleeding patterns and make bleeds less heavy. They can also improve acne in some women. They also reduce the risk of endometrial, ovarian and bowel cancer.

Use: The COC is usually taken daily for twenty-one days followed by a seven-day break after which the pill is restarted. It has to be taken within 24 hours of the same time each day.

The EVRA patch is changed every seven days with a seven-day break after three weeks.

The vaginal ring is left in for twenty-one days followed by a seven-day break.

However, not taking a break or reducing the number of breaks may increase the effectiveness of these methods, as does reducing the break to 4 days. This is safe to do and reduces the number of bleeds you have.

Please read further information here for the COC pill, here for the patch, here for the vaginal ring.

We need to check that there is nothing in your medical history that might make it unsafe to use these methods. The questions below are common for all Combined hormonal contraception methods (COC pill, EVRA patch, vaginal ring).

You will need to provide your recent height, weight and blood pressure as part of this process.

Combined hormonal contraception is offered only to women below the age of 50.
What is the name of the Combined hormonal contraception you are using?
Are you finding it difficult to remember to take the pills on time (for COC) or use the patches or vaginal ring correctly? Yes No
Have you been late or missed any pills, patches or the ring in the last three months? Yes No
Have you used emergency contraception in the last three months? Yes No
Do you think you might be pregnant? Yes No
Have you been pregnant in the last 3 months? Yes No

Please enter details.
Are you currently breast feeding? Yes No
Have you had any unexpected vaginal bleeding? Yes No
Are you taking any medication that you have been prescribed or bought? Yes No

Please enter details, name of the medication and the reason for taking it.
Are you taking St John’s wort? Yes No
Do you have any allergies (including peanut and soya allergies)? Yes No

Please enter details.
Have you ever been advised not to take oestrogen containing medication? Yes No
Have you smoked any cigarettes, tobacco or vaped in the last 12 months? Yes No

Please enter details.
Have you ever had any of the following conditions:
- high blood pressure
- diabetes
- breast disease
- cancer of any type
- thrombosis/blood clot eg (DVT: Deep Vein Thrombosis or PE: Pulmonary Embolism)
- stroke (or TIA)
- heart disease
- liver disease, jaundice or gall stones
- high cholesterol
- antiphospholipid antibodies
- malabsorption syndromes
- gastrointestinal surgery
- restricted mobility
Yes No
Have you had any illnesses or operations (in the past or present)?
Please provide details, approximate dates and outcome: Yes No

Please enter details.
Have you ever had a migraine? Yes No
Has anyone in your close family, (mother, father, brother, sister) had breast cancer, a heart attack, stroke or thrombosis (blood clots)?
Are there any health conditions that run in your family? Yes No

Please enter details such as who had what condition and how old were they when diagnosed with it.
Have you seen any other contraceptive provider since your last prescription from CNWL Sexual Health services and if so what for? Yes No

Please enter details.
What is your weight in Kg
What is your height in metres
Body mass index
Your BMI is

What is your blood pressure (XXX/XX)
Everybody’s blood pressure (BP) is different and it can change without you noticing. Combined hormonal methods of contraception can increase one’s BP in a small percentage of women. High BP increases the risk of heart attack and stroke. It is important that you provide us with a BP measured within the last one month so that we can ensure that it remains within the acceptable range. You can measure your BP at many places, GP, gyms and pharmacists. You can also buy BP monitoring devices from pharmacies and online.
Has this blood pressure been measured in the last one month? Yes No
How many months’ supply do you want?

Thank you for providing us with your health information.

The information you have provided will be reviewed by a clinician. The clinician will decide if you are eligible for online contraception. They may call you to clarify details if felt necessary. If you are eligible, you will be sent the contraception or a prescription in the post to the address you provide below. If it is a prescription you take this into any high street chemist and you will receive your contraception.

If the clinician reviews your health information and decides that you might benefit from a consultation then you will be contacted via email or text.

Please complete the form below.

We will record this information and create a patient record if you are a new patient, if necessary we will update records of existing patients.

We will be sending you a home self-test kit that includes...

We will post your kit to you. You take your own samples and send it back.
You’ll get your results by text or we will call you.

You can only order a home self-test kit for yourself. Please do not try to place orders for other people.

Please complete the form below.

We will record these details in your patient record and share them with our third party supplier, TDL (The Doctors Laboratory), who will supply your home self-test kit and carry out the testing on your returned samples.

Date of Birth

/ /

You need to be between 18 and 54 to be eligible for online POP prescription.

You need to be between 18 and 49 to be eligible for online Combined hormonal contraception prescription.

Note: Your eligibility to receive a self-test kit depends on your postcode and changing this may reset the above information. Only UK mobile numbers will be accepted.

Note: Your eligibility to receive online contraception depends on your postcode, and changing this may reset the above information. Only UK mobile numbers will be accepted.

We will record whether you are male or female based on the kit you have ordered.

The information below is required for anonymous bulk reporting for health planning. The information in reports cannot be linked to you as an individual and will only be shared for NHS purposes.

* Fields are mandatory.

Please click here on Progestogen-only Pill to read information about the use, risks and benefits of this method of contraception.

Please click here for the COC pill, here for the patch, here for the vaginal ring to read information about the use, risks and benefits of this method of contraception.

I agree that CNWL can share my details with TDL * I have read and understood all of the questions, and answered these to the best of my ability. I understand that all medication, including contraception, can have risks and side effects and I have read and understood these in relation to the contraception I am requesting. *

Please enter your validation code:

Didn’t receive a text? Please check your mobile number is entered correctly.

Thanks for your order

You should receive your home self-test kit within a week.

Please read the instructions included in your kit carefully before you take a test.

If you have not received your home self-test kit after one week, you can contact us at cnw-tr.surreyselftest@nhs.net. This inbox is monitored Monday to Friday, 9am to 5pm.

If you need support because you feel frightened of your partner or you’re worried about drugs and alcohol, please visit this page.

Thank you for submitting the form for online contraception

Your answers will be reviewed by a clinician. Sometimes the clinician might need to call you to clarify the information you have provided, this will usually be within 5 working days after your request.

If you are suitable, medication or a prescription will be sent by post and may require a signature. If a prescription, you can take it to any chemist to receive your free contraception.

This will be issued on the understanding it is for your use only and for contraceptive purposes.

We will let you know by text if we are not able to prescribe contraception online and you will be advised to make a phone consultation instead.

Domestic abuse / violence

What is sexual abuse?

Thanks for your order

Thank you for requesting a test

Thank you for submitting the form for online contraception