Coils and Implants

Please use the form to request a referral for a coil (IUD or IUS), or implant fitting or removal.

This service is offered by a number of local GP surgeries in City and Hackney, as an alternative to having this done in sexual health clinics run by hospitals.

If you wish to be seen by Homerton Hospital's Sexual Health Clinic, do not complete this form - instead you can self-refer here.

It is important that you read this information on different methods of long-active reversible contraception. Please do so before completing this form.

Your details

First Name(Required)

Surname(Required)

Date of Birth(Required)

NHS Number (if known)

Address(Required)

Address Line 1 Address Line 2 City Postcode

Contact Telephone Number(Required)

What would you like to be referred for?(Required)

Coil fitting / replacement

Coil removal

Implant fitting / replacement

Implant removal

Your relevant medical history

Please complete this section fully. This information is necessary in order to complete your referral.

Are you currently using contraception?(Required)

Yes

Have you ever had a coil?(Required)

I currently have a coil

I have previously had a coil

I have never had a coil

Do you have any children?(Required)

Yes

If yes, how many children do you have?(Required)

What is the age of your youngest child, in years?(Required)

How did you deliver your youngest child?(Required)

Vaginal delivery

C-section

Not sure / Can't remember

Are you currently breastfeeding?(Required)

Yes

What date was the first day of your last menstrual period?(Required)

For how many days do you typically bleed whilst on your period?(Required)

Are your periods typically:(Required)

Light

Medium

Heavy

Other

Do you have any other relevant information that you wish to share?

Where do you want to be referred?

Please note, the Heron Practice only do coil fittings and removals. They DO NOT fit or remove implants. Please select a different option if you are looking to have a implant fitted or removed.

Untitled(Required)

Heron Practice - John Scott Health Centre, Green Lanes, N4 2NU

Statham Grove Surgery - 7 Statham Grove, N16 9DP

Nightingale Practice - 10 Kenninghall Rd, Lower Clapton, E5 8BY

Disclaimer

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

The information you provide will be processed with the sole purpose of providing you with Direct Care within the surgery and in support of Direct Care elsewhere. Our Privacy Policy provides further detail about how we process your personal information for the purposes of Direct Care.

You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

Coil and Implant Fittings and Removals - Referral Form

Your details

Your relevant medical history

Where do you want to be referred?