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Contraception self referral form

CONTRACEPTION SERVICE

SELF-REFERRAL FORM for contraception service

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. We currently carry out our initial coil assessments via telephone, to ensure suitability, before arranging a face-to-face appointment for fitting.

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…

(if known)
MM slash DD slash YYYY
Name
Address
Do you consent for letters to be sent to the above address?

Please provide emergency contact information below

Name

Required Medical Information

Do you need emergency contraception?
Current contraception (if any)
Which type of contraception would you like assessed for?
(Please detail)
Any previous treatment for abnormal smears?
Do you have a history of fainting?
(Please detail)
(Please detail)

If you are requesting assessment for an intrauterine coil (hormonal or copper), please answer the following questions

Have you had a coil fitted previously?
Were there any problems with your previous fitting eg fainting or fit failure?
Have you had any previous coil problems/expulsions/perforation?
Are you currently breast feeding?

Important information

Heavy periods and Dysfunctional Bleeding

For your safety, we are unable to fit coils for the sole purpose of managing bleeding symptoms. Patients with the following symptoms should seek advice from their GP:

  • New onset/ heavy menstrual bleeding
  • Intermenstrual bleeding (bleeding between periods)
  • Postcoital bleeding (bleeding after sexual intercourse)
    • Further information on these symptoms, and why we would advise you to see your GP, is available here: wuth.nhs.uk


    HRT

    Coils that are to be inserted for the sole purpose of the progesterone element of hormone replacement therapy, or management of heavy bleeding associated with menopause, require a referral to gynaecology via your GP. We are unable to replace coils that were inserted when you were over the age of 45. Mirena coils are licenced for use in contraception until the age of 55, when they are inserted over the age of 45. They have a shorter licence for HRT treatment. Please speak to your GP if your coil has expired for HRT.


    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 Free Home STI STD Test | Sexual & Reproductive Health (sh24.org.uk). If this is done prior to your telephone appointment, we may be able to offer you an earlier face-to-face appointment.

    Further information about contraception and your options is available here: Contraception – Sexwise

    Have you read the information below?

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