Long acting contraception self-referral form

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Confirmation

By completing this form you will be temporarily registered with this GP Surgery, this will not affect your current registration your own GP Surgery

All information collected on this form and during any appointments offered are confidential. however, your current GP Surgery will be notified once the procedure is complete.

It is vital that all questions are completed as accurately as possible.

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Information about your choices

Please take the time to read the information below to allow you to make an informed decision about your needs.

You will be given the opportunity to ask any questions you may have at your telephone assessment.

Implant

What is a Contraceptive implant

Hormonal coils

What is a IUS (Intrauterine system)

We offer 2 different hormonal coils

Jaydess
- lowest dose hormonal coil
- used for 3 years.
Mirena
- low dose coil
- newly licensed for 8 year use for contraception

Non hormonal coil

What is a IUD (Intrauterine device)

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Personal Details

Please double check you've entered the correct mobile number

Please double check you've entered the correct email address

HOW TO FIND YOUR NHS NUMBER

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Contraception

Do you require a: *

Your choice of Contraception: *

Are you currently using any other type of contraception: *

Pill, patch, ring, injection

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Assessment

Have you recently had sexual intercourse without using a condom: *

Have you recently given birth: *

Are you currently breastfeeding: *

Do you have any vaginal bleeding that you’re concerned isn’t normal?: *

Have you discussed this with a healthcare professional already: *

Please book an appointment with a GP or specialist Nurse, your referral may be rejected.

You cannot continue with this form: *

Have you recently had any sexual health tests: *

Are you being seen at the hospital because of an abnormal smear result: *

Do you have a history of, or do you currently have breast cancer: *

Do you have any history of heart disease or a stroke: *

Do you have any history of liver disease: *

Do you have any issues with your immune system or take any medications that may cause you to be immunocompromised: *

Do you have a history of fibroids (benign growths inside your womb): *

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Declaration

Privacy Consent

This form collects personal and medical information about you. 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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Long acting contraception self-referral form

Implant

Hormonal coils

We offer 2 different hormonal coils

Non hormonal coil

Privacy Consent

CONTACT DETAILS

FEEDBACK

PRACTICE POLICIES

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