Contraceptive Coil Appointment Request

Contraceptive Coil Appointment Request

Please fill in this form if you would like to book an appointment for a coil fitting. Please note that our coil fitter Dr Meade is a male doctor. He will have a chaperone with him during your appoinment. A member of the reception team will be in touch with your appointment.
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number

Area CodePhone Number
Phone number
New guidelines for Mirena and Levosert state the coils can be used for 8 years for contraception. This increases to 10 years if fitted when aged 45 years or older. Mirena can be used for 5 years for HRT. Please check whether you still need your coil replacement with these changes.
I would like to have:

coil fittingcoil removalcoil removal and fitting of new coil
Please read the information in the following links:

https://harbornemedical.co.uk/health-and-wellbeing-at-harborne-medical/womens-health/coil-clinic

https://patient.info/sexual-health/long-acting-reversible-contraceptives-larc/intrauterine-contraceptive-device

https://patient.info/sexual-health/long-acting-reversible-contraceptives-larc/intrauterine-system

You may also wish to view this video which provides information about after a coil is fitted:

https://youtu.be/TTrhmM05mng
I have read and understood the information about coils and I am happy to proceed. (Please book an appointment with a doctor if you need to discuss anything further)

YesNo
I am happy to receive my appointment by text message. (If the appointment time is unsuitable, you will be able to respond to the text message with the text REARRANGE and an alternative will be offered)

YesNo
Special Requirements (eg translator, mobility problems etc)
Should be Empty: