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Contraception self referral form

CONTRACEPTION SERVICE

SELF-REFERRAL FORM for contraception service

Step 1 of 2

Once you submit the form your name will be added to the appropriate waiting list, and you will be contacted when an appointment is available.

Further information on contraception and your options is available at Contraception Choices.

Please complete the form with as much information as possible – we ask these questions to make sure we triage your contraceptive needs appropriately and provide you with the best possible care in the most efficient way we can.

*MIRENA COIL UPDATE: The Mirena Coil has now been licensed to work for 8 years for contraception. If you had a coil fitted for contraception only and was previously told this would last 5/6 years, this coil can now be kept in for 8 years. However, please note if you are using this for contraception as well as heavy bleeding or HRT this may still need changed at 5 years. If you are over 55 and using Mirena as part of HRT, you will require a referral by your GP to the GP Federation.

** GREAT IMPLANT NEWS** Nexplanon can now be used for 5 years as contraception. This means you do not need your current implant changed for another 2 years. Your implant will be due a change 5 years from the date of fit. Please contact our service 3 months before this date so we can arrange for your implant to be changed. You can read more about this new development in the College of Sexual and Reproductive Health’s statement.

Name(Required)
DD slash MM slash YYYY
**All our calls will be from a withheld/unknown number – please check your phone settings to ensure there is no block on unknown callers. On the day of your telephone appointment, clinicians will only try to contact you on two occasions.
Do you consent to being contacted by email?(Required)
Address(Required)
What gender do you identify as?(Required)
Have you used our service previously?(Required)
How can we help?(Required)

Important information

This is a Trust-wide service, and we offer appointments in different Trust locations; you may have to wait longer for an appointment in your preferred location.


Once you submit the form your name will be added to the appropriate waiting list, and you will be contacted when an appointment is available.

STD Testing

We currently require all our patients to perform sexually transmitted infection checks for coil fitting to reduce risk of infection from the procedure. We advise you to order the discreet and confidential free test kit from SH:24. If this is done prior to your telephone appointment, we may be able to offer you an earlier face-to-face appointment.

Have you read the information above?(Required)

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