Contraception self referral form

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 contraception and your options is available here: Contraception – Sexwise We ask so many 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 and you will require a referral to Gynae or GP federation for this.

Name(Required)

First Last

Date of birth(Required)

Telephone Mobile/Landline(Required)

**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.

Email(Required)

Do you consent to being contacted by email?(Required)

Yes

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

GP Name and Surgery(Required)

What gender do you identify as?(Required)

Male

Female

Transgender

Non-Binary

Other

Have you used our service previously?(Required)

Yes

Not sure

How can we help?(Required)

Coil – Insertion/Replacement/Removal/Issues

Implant – Insertion/Replacement/Removal/Issues

Emergency contraception

Pills – Please visit our partner SH24 for free and discreet delivery of up to 12 month supply (or if you wish to discuss pill use with our service – select this option)

Depo Provera/Syana Press (self-injectable)

Condoms

Other

If other/issues, please specify.

If you require an interpreter, please provide language below.

Do you require any special assistance? If so, please specify.

Are you on any medication at present? If yes, please give details.

Are you on any weight loss injections or have you used these in the past 2 months? (these can affect contraception and unknown safety in pregnancy).

Any additional information/medical history relevant to this referral?

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.

CONTRACEPTION SERVICE

Important information

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