Refer yourself for long acting contraception fitting (coil/ implant) Long Acting Contraception Self-referral Form ConfirmationBy completing this form you will be temporarily registered with this GP Surgery, this will not affect your current registration your own GP Surgery All information collected on this form and during any appointments offered are confidential. however, your current GP Surgery will be notified once the procedure is complete.It is vital that all questions are completed as accurately as possible. I understand that by completing this form I will be temporarily registered with this GP Surgery, this will not affect your current registration status with your own GP Surgery. I understand that my current GP Surgery will be notified once the procedure is complete. Information about your choicesPlease take the time to read the information below to allow you to make an informed decision about your needs. You will be given the opportunity to ask any questions you may have at your telephone assessment.Contraception Choices – ImplantContraception Choices – CoilWe offer 2 different hormonal coils Jaydess lowest dose hormonal coil used for 3 years. Mirena low dose coil newly licensed for 8 year use for contraceptionContraception Choices – Non Hormonal CoilPersonal DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Gender Male Female Date of Birth DD slash MM slash YYYY Home Phone NumberMobile Phone NumberPlease double check you’ve entered the correct mobile numberEmail Address Please double check you’ve entered the correct email addressHOW TO FIND YOUR NHS NUMBERContraception Information1. Do you require fitting or removal? 2. Are you using any other contraception 3.Choice of contraception coil vs implant 4. Last Menstrual Period 5. Breastfeeding Yes No 6. Abnormal vaginal bleeding Yes No 7. Recent sexual health tests including date (tick box to confirm consent that may be asked to test before attending) I give Consent Yes No 8. Recent treatment for STI including date 9. Date of last smear and if you are being seen at the hospital for an abnormal smear result 10. Recent unprotected sexual intercourse (without a condom) Yes No 11. History or family history of breast cancer Yes No 12. History of heart disease or stroke Yes No 13. History of liver disease Yes No 14. History of conditions that may cause immunocompromise or taking any medication that may compromise your immune system Yes No 15. History of fibroids (benign growths in your womb) Yes No DeclarationI understand that all procedure on this form have certain risks associated with its use and the procedure, as outlined in the information previously provided in this form, and I will have the opportunity to discuss this further in my assessment. All information provided is correct to the best of my knowledge.