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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.

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: please note if you require a coil replacement, The Mirena Coil has been recently licensed to work for 8 years. If you had a coil fitted for contraception only and was previously told this would last 5 years, this coil can now be kept in for 8 years. If you are using this for contraception and heavy bleeding or HRT this may still need changed at 5 years and will need assessed.

(if known)
MM slash DD slash YYYY
Name
Address
I give consent to be contacted by:

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

    We are unable to fit/change coils used for the sole purpose of HRT. A Mirena coil must be changed after 5 years at any age when used for HRT treatment. Please speak to your GP if your coil has expired for HRT.


    Coil Duration of Use/Replacements
  • In January 2024, Bayer updated its license for the Mirena coil, stating that that ‘any 52 mg LNG-IUD inserted < 45 years can be used for contraception for 8 years.’ When inserted at age ≥45 years, the Mirena coil can be used for contraception until age 55 years.
  • The Kyleena coil can be used for contraception for 5 years.
  • Any Copper-IUD with copper surface area ≥300 mm2 (eg Nova-T and T-Safe) inserted ≥40 years can be used for contraception until menopause. It can be removed 1 year after the final menstrual period if this occurs after age 50 years. If <40 years old at time of insertion, Nova-T IUD has a 5 year licence and the T-Safe IUD has a 10 year licence. Please check what coil you have, if it was inserted in another clinic.
  • 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.

    Emergency copper IUD
  • Please contact us by completing our online form or emailing the service at contraception@southerntrust.hscni.net at the earliest possible instance to facilitate prompt treatment.
  • Please check that the phone number provided is correct and expect a call from a withheld number.
  • If you have not received correspondence within 4 hours, or by 11:30am the next working day if referral made after 4.00pm, please email or phone the service to ensure we have received the initial referral.
  • In the instance of referrals made by other health professionals: Please issue/prescribe the patient with oral emergency contraception where not contraindicated, in case of potential coil fit failure.
  • Further information about contraception and your options is available here: Contraception – Sexwise