Refer yourself for long acting contraception fitting (coil/ implant)

Long Acting Contraception Self-referral Form


By 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.

Information about your choices

Please 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.

We offer 2 different hormonal coils


lowest dose hormonal coil

used for 3 years.


low dose coil

newly licensed for 8 year use for contraception

Personal Details

DD slash MM slash YYYY
Please double check you’ve entered the correct mobile number
Please double check you’ve entered the correct email address

Contraception Information

5. Breastfeeding
6. Abnormal vaginal bleeding
I give Consent
10. Recent unprotected sexual intercourse (without a condom)
11. History or family history of breast cancer
12. History of heart disease or stroke
13. History of liver disease
14. History of conditions that may cause immunocompromise or taking any medication that may compromise your immune system
15. History of fibroids (benign growths in your womb)


I 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.