Reception: Coil & Implant Fitting/Removal Request Form
THIS FORM IS FOR CLARENDON LODGE PATIENTS ONLY. IF YOU ARE A PATIENT AT ANOTHER PRACTICE & WOULD LIKE TO REQUEST A FITTING PLEASE CONTACT YOUR OWN PRACTICE INITIALLY.
Long-acting contraception can provide a safe and effective method of contraception.
There are two different types of coil:
- One which contains hormones (an intrauterine system, or an IUS for short)
- And one which does not contain hormones (an intra-uterine device, or IUD for short)
The hormonal coil (IUS) can be used for contraception and also as part of hormone replacement therapy.
The non-hormonal coil (IUD) can only be used for contraception.
The NHS choices and sexwise website contain more information about the differences between the non-hormonal and hormonal coils.
If you are considering using a coil or would like to have a current coil replaced or removed then please:
Please fill in as much information as possible to help us arrange your appointment efficiently.
Some of this information will already be included in your medical notes but this is a good opportunity to update any changes.
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 5 working days to complete. Please DO NOT call before 5 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.
There are now 3 different types of hormonal coil available for contraception in the UK. However, only the Mirena can be used for HRT.
This is to ensure that you have enough contraception to last until you have your implant or coil fit
It is really important we do not fit a coil or implant if there is a risk of pregnancy.
Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or leave this question blank
If you would like your coil removed or replaced it is important to use condoms or abstain from sex for 7 days prior to the appointment. This is because sperm can survive for up to 7 days.
We also want to ensure there is no risk of sexually transmitted infections. Please answer the following questions:
Some medical problems mean that certain methods of contraception are not suitable. Please fill in the following information:
If you would like an implant then you do not need to answer this question
And a few final bits of information
If you are not a registered patient then this form will be discarded.
Thank you very much for completing this form. We will aim to contact you within 5 working days.
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.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.