LARC Self Referral Form
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
To be eligible for our service you must be aged 55 or under
NHS Number
*
If you do not know your NHS number please follow this link https://www.nhs.uk/nhs-services/online-services/find-nhs-number/
Please select your ethnicity
*
Please Select
African
Any other Asian background
Any other Black, Black British, or Caribbean background
Any other ethnic group
Any other Mixed or multiple ethnic background
Any other White background
Arab
Bangladeshi
Caribbean
Chinese
English, Welsh, Scottish, Northern Irish or British
Gypsy or Irish Traveller
Indian
Irish
Pakistani
Roma
White and Asian
White and Black African
White and Black Caribbean
Prefer not to say
Email
*
example@example.com
Mobile Phone Number
Please enter a valid phone number.
Are you a Wokingham Borough resident?
*
Please Select
Yes
If you are unsure please follow the link to confirm: Find your local council - GOV.UK
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Next of Kin and Contact Number
What type of Long Acting Reversible Contraception are you looking to have fitted or removed? (Please note we cannot provide LARC for emergency contraception purposes).
*
Non-hormonal Coil (Copper Coil)
Hormonal Coil
Implant
I'm not sure
Have you have a coil before?
*
Yes - I have one currently and would like it replaced
Yes - I have had one in the past and would like another one fitted
Yes - I would like it removed
No
If you are requesting a coil replacement, please confirm what this is for
*
Contraception
HRT
N/A
Have you had an implant before?
*
Yes - I have one currently and would like it replaced
Yes - I have had one in the past and would like another one fitted
Yes - I would like it removed
No
Have you had any new sexual partners in the last 12 months?
*
Yes
No
Have you had a sexual health screen in the last 12 months?
*
Yes
No
When the the 1st day of your last period?
-
Day
-
Month
Year
Date
Have you ever been told that your uterus (womb) is not a normal shape or that you have fibroids?
*
Yes
No
Is there any chance you could already be pregnant?
*
Yes
No
Have you had a baby in the last 12 weeks?
*
Yes
No
Are you currently breast feeding?
*
Yes
No
What is your current method of contraception?
*
Have you been using this method reliably?
*
Yes
No
Are you up to date with your smear test?
*
Yes
No
Are you experiencing any unexplained vaginal bleeding?
*
Yes
No
Are you taking any regular medication (including over the counter treatments)?
*
Is there anything you would like to ask about having a coil/implant fitted or removed?
*
Please detail any additional assistance you require during your phone assessment or clinical appointment
Signature (by signing this form you consent to MHH accessing your medical record)
*
Submit
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