Coil Form

If you have an existing coil that needs to be replaced or would like to have a coil inserted, please complete the questionnaire. The information provided will help us know if it is appropriate for you to have a coil and allocate you an appointment.

The practice will contact you in the next 14 days after completing this form.

Last Updated: 30/04/2024

  • Personal Details

    Date of Birth
    For example, 15 3 1984

  • Further Information

    When was your last proper menstrual period?
    For example, 15 3 1984
    Do you have any irregular bleeding?
    Do you have any previous/current gynaecological conditions?
    Is there any risk of pregnancy? e.g. unprotected sexual intercourse after last period, any missed contraception and unprotected sexual intercourse.
    Are you currently breastfeeding?
    Have you recently had a baby in the last month?
    Have you previously been tested for sexually transmitted infections?
    If yes, when? (optional)
    For example, 15 3 1984
    Do you have any allergies?
    What coil would you like to use?
    Have you had any complications after previous coil insertions?
    Are you taking HRT?
    Are you taking any vaginal moisturisers/pessaries?

  • Consent

    This form collects your name, date of birth, other personal information and medical details. This is to confirm you are registered with the practice, to allow Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.
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