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Home > Reception: Coil & Implant Fitting/Removal Request Form

Reception: Coil & Implant Fitting/Removal Request Form

Long-acting contraception can provide a safe and effective method of contraception.

There are two different types of coil:

One which contains hormones (an intrauterine system, or an IUS for short)
And one which does not contain hormones (an intra-uterine device, or IUD for short)

The hormonal coil (IUS) can be used for contraception and also as part of hormone replacement therapy.

The non-hormonal coil (IUD) can only be used for contraception.

The NHS UK and sexwise website contain more information about the differences between the non-hormonal and hormonal coils.

If you are considering using a coil or would like to have a current coil replaced or removed then please:

Read through this information
Watch the video on the relevant procedure
Carefully read through the consent form
And then submit the online form below. We will aim to contact you within 5 working days of receiving the form to arrange an appointment.

Please fill in as much information as possible to help us arrange your appointment efficiently.

Some of this information will already be included in your medical notes but this is a good opportunity to update any changes.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Personal details

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Appointment details

What type of appointment would you like?

If you would like an appointment for a coil do you know which type of coil you would like?There are now 3 different types of hormonal coil available for contraception in the UK. However, only the Mirena can be used for HRT.

If you would like a hormonal coil inserted or replaced is this for (please select all that apply):

Contraception

Management of heavy periods

HRT

Are you currently using contraception? And if so which method?

If you would like to change please explain why

If you currently have an implant or coil what date is the replacement due?

If you are using another method of contraception do you have enough to last you 2 months? This is to ensure that you have enough contraception to last until you have your implant or coil fit

Further information

It is really important we do not fit a coil or implant if there is a risk of pregnancy.

Are you concerned you might be pregnant?

Do you know the date of your last period?Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or leave this question blank

If you would like your coil removed or replaced it is important to use condoms or abstain from sex for 7 days prior to the appointment. This is because sperm can survive for up to 7 days.

We also want to ensure there is no risk of sexually transmitted infections. Please answer the following questions:

Are you concerned you might have a STI?

Have you had a STI previously?

Are you experiencing any vaginal bleeding after sex or unusual vaginal discharge?

Some medical problems mean that certain methods of contraception are not suitable. Please fill in the following information:

Do you have or have you ever been diagnosed with:

Breast cancer

Any family history of inherited breast cancer (such as BRCA mutations)

Previous gynaecological surgery

Fibroids

None

If you would like a coil have you ever had a baby born by vaginal delivery?If you would like an implant then you do not need to answer this question

Any previous history of breast cancer?

Any family history of inherited breast cancer?

And a few final bits of information

Any previous gynaecological surgery?

Do you have any allergies? (If none write NO)

Have you given birth via a vaginal delivery?

What is your smoking status?

How many units of alcohol do you consume per week?

Have you previously had a sexually transmitted infection or are you concerns you might currently have one?

I confirm that I have read through the above linked consent form which contains information to ensure a coil or implant can be fitted safely and without a risk of pregnancy

Thank you very much for completing this form. We will aim to contact you within 5 working days.

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend your appointment at the surgery. Instead cancel your appointment and self-isolate for 7 days. Visit out Coronavirus page for more information. https://www.clmp.org.uk/Information-Zone/Coronavirus-Navigation-Hub

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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