Long Acting Contraceptive Service (LARC) Coil Self-Referral Form

If you would like to have a contraceptive coil fitted, exchanged or removed please fill in this online form.

Please do not bring young children to the clinic during appointment/procedure unless discussed with the clinic in the first instance.

Long Acting Contraceptive Service (LARC) Coil Self-Referral Form

Type of referral

What type of referral are you making?

Coil exchange Optional

Coil new insertion Optional

Coil removal Optional

Patient details

Name

First Last

Date of birth

Day

Month

Year

Contact number

Address

Street Address Address Line 2 City Postcode

Email address

Ethnicity

Please specify

Country of birth

Gender

Is your gender the same since birth?

Sexual orientation

Other Optional

Do you need an interpreter at the face-to-face appointment?

Yes

What language do you need?

Exchange

I have had this coil in place for

Where was your device fitted?

New insertion

What contraception are you currently using?

Combined Hormonal Contraception (Pills/Patch/Ring)

Progestogen only contraception (Injection/Implant/Pill/IUDC

Non-hormonal Contraption (Condoms/Copper Coil / Diaphragm or cap)

None – Withdrawal/ Natural family planning -ovulation tracker

Removal only

Removal of contraceptive coil needs to be done during a face to face consultation with a health care professional.

It is important, in order to avoid risk of pregnancy after removal of your device that you abstain from unprotected sexual intercourse in the 7 days before your appointment.

If you require removal and another form of contraception please call the Central Access Team on 0300 790 0245.

I have had this coil in place for

Please call the Central Access Team on 0300 790 0245 .

Where was your device fitted?

Other

There are several reasons why you may want your coil removed:

Please tell us more

Medical questions

Have you ever had any of the following conditions?

Breast Cancer /cancer of any type

Epilepsy

Heart disease or irregular heart rhythm

High cholesterol

Organ transplant

Unexpected vaginal bleeding

Molar pregnancy

Sexually transmitted infection such as PID, Chlamydia or Gonorrhoea

Fibroids or abnormality of the womb

Pelvic TB

HIV

None of the above

Other (please specify below)

If you have any medical health problems please tell us more about your condition

Are you taking any medication that you have been prescribed or bought over the counter?

Yes

Please tell us what you are currently taking

Do you think you might be pregnant?

Yes

Are you breastfeeding?

Yes

We would like to speak to you please call 0300 790 0245 or 0300 123 1678.

Have you had any unexpected vaginal bleeding recently? Such as bleeding after sex or bleeding between periods.

Yes

Please add details

Do you have any drug or other allergies? (including peanut, soya allergies or are lactose intolerant)

Yes

Please add details

How often do you have periods and when was your last one? Optional

Are your periods painful or heavy? Optional

When was the last time you had any sexual contact with anyone? Optional

Was the sex…

Protected (condom used) Optional

Unprotected (condom not used) Optional

Are any of the following applicable to you? In the last three months…

Have you had a sexual partner from another country/region other than Western Europe, North America or Australia Optional

Do you have any tattoos or piercing that have been done unprofessionally (stick and poke / bamboo tattoo / prison tattoo)? Optional

Have you been paid for sex? Optional

Have you paid for sex? Optional

Have you received any medical treatment in another country (operation/blood transfusion/injection)? Optional

Have you had a blood transfusion? Optional

None of the above Optional

Please give details Optional

Have you had any new sexual partners in the last 3 months?

2 to 4

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on 0300 790 0245 or 0300 123 1678.

Do you smoke or vape?

NHS stop smoking services help you quit – NHS (www.nhs.uk)

How often do you have a drink containing alcohol?

Never – I do not drink alcohol

Once a month or less

2 to 4 times a month

2 to 3 times a week

4 or more times a week

I do not want to answer

If you feel that your drinking is becoming an issue and you would like to access some help please visit Drink less – Better Health – NHS (www.nhs.uk)

Are you currently or have you ever experienced any of the below?

Sexual assault Optional

Domestic abuse Optional

Mental health issues Optional

I do not want to answer Optional

This is not applicable to me Optional

Would you like one of our clinicians to call you to discuss and offer additional support/advice?

Yes

No (I am safe and have received or am receiving support with this from other services and do not require contact at present)

How would you like us to contact you?

Text

Phone

Date completed

Month

Day

Year

Consent

I confirm I would like an IUCD/ Coil fitted for the purposes of contraception

Yes