Reception: Clarendon Lodge Coil Form
Coil insertion/replacement 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 main groups of of coil:
- The hormonal coil (an intrauterine system, or an IUS for short)
- And the non hormonal coil (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. There are now several types availabe - these vary in amount of hormone released, size and length of time that contraceptive cover is provided. Only the Mirena coil can be used as part of HRT.
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 replaced 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.
If you would like a hormonal coil for contraception and have a preference relating to the type please also include these details here
It is unsafe to fit a coil if there is a risk of pregnancy. For this reason it is essential that you are reliably using contraception or abstaining from sex for 3 weeks prior to your appointment. If you are having a coil (which is in date)replaced you should use alternative contraception or abstain from sex for 7 days before the appointment. This is to avoid pregnancy if there difficulty in fitting the replacement coil.
As previously mentioned it is really important we do not fit a coil if there is a risk of pregnancy.
If you are having your coil replaced it is also 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, and so if your current coil is removed and there is difficulty inserting the replacement there could be a risk of pregnancy if you have had sexual intercourse in the week prior to the appointment.
Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or leave this question blank
To safely fit a coil we also want to ensure there is no risk of sexually transmitted infections.
Some medical problems mean that certain methods of contraception are not suitable. Please fill in the following information:
Knowing some obstetric information can also help us manage your appointment.
There is a higher risk of complications when fitting a coil if you are within 12 weeks of giving birth. If you have recently had a baby ideally we would suggest using alternative contraception until you are 12 weeks post natal and we will arrange your appointment for after this time period
And a final few bits of information
If the answer is no then you must complete this first prior to submitting the form
Thank you very much for completing this form. We will contact you as soon as possible.
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.