Reception: Pessary Change

Please complete this form if you would like to request a vaginal pessary change. Reception will contact you to arrange a convenient time to visit the surgery.

A vaginal pessary is a device made of rubber (latex) or silicone is inserted into the vagina and left in place to support the vaginal walls and pelvic organs.

Vaginal pessaries allow you to get pregnant in the future. They can be used to ease the symptoms of moderate or severe prolapses and are a good option if you cannot or would prefer not to have surgery.

Vaginal pessaries come in different shapes and sizes depending on your need. The most common is called a ring pessary.

You may need to try a few different types and sizes to find the one that works best for you.

 

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 3 working days to complete. Please DO NOT call before 3 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

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Reception: Pessary Change

If you do not have a pessary already please indicate below which chemist you would like us to send the prescription to.

The pessary can then be collected prior to your appointment and brought with you.

Thank you for completing this form

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend your appointment at the surgery. Instead cancel your appointment and self-isolate for 7 days. Visit out Coronavirus page for more information. https://www.clmp.org.uk/Information-Zone/Coronavirus-Navigation-Hub


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Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

Information submitted through all secure forms, with the exception of the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form, is secured with a private key and is accessed over a secure connection by nominated staff. Information submitted through the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form is sent to The Leamington Primary Care Network via secure email.

We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 365 days.

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