IUC Self Referral

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Do you require an interpreter?: *
What type of Coil would you like?: *
What contraception are you currently on? (Please Tick): *
Have you missed or been late for any pills/patches/ring/Injection in the last 3 months?:
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Do you have any of the following illnesses or medical conditions::
Was your copper coil (IUD) fitted age 40 or over?:
Was your hormonal coil (IUS) fitted age 45 or over?:
Have you had any problems having a Coil fitted previously? (fits or fainting) had to have it fitted under General anaesthetic?: *

If you have ticked yes to certain health conditions you may receive a phone call to discuss this.

Have you had a negative test for chlamydia and gonorrhoea in the past 3 months?: *

You are recommended to do a test to ensure you do not have a sexually transmitted infection.

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