Coil Insertion Form

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

Reason for coil *

Contraception

Heavy menstrual bleeding

HRT

Which coil would I like *

Mirena

Jaydess

Kyleena

Current bleeding pattern **IF YOU HAVE BLEEDING AFTER SEX, HEAVY IRREGULAR BLEEDING OR BLEEDING IN THE MIDDLE OF A CYCLE PLEASE CONTACT THE SURGERY TO DISCUSS WITH A CLINICIAN BEFORE COIL INSERTION *

I have watched the video on IUDs or read online information *

Yes No

I understand I need to use an effective method of contraception and have no problems e.g. burst condom, missed pills, IUD overdue for change. I have not had unprotected sex (or used withdrawal) since my last period *

Yes No

I understand that it is not safe to insert an IUD if I might be pregnant *

Yes No

I will make sure that I have had breakfast on the day of the appointment. Paracetamol/ibuprofen is useful an hour before your appointment *

Yes No

I DO NOT have symptoms of sexually transmitted infection (STI) - vaginal discharge, rash, pain on passing urine or unusual bleeding. **IF YOU HAVE ANY OF THESE SYMPTOMS PLEASE CONTACT THE SURGERY TO MAKE AN APPOINTMENT TO DISCUSS WITH A CLINICIAN** *

Agree

Disagree

I understand that no method is 100% effective and that the hormonal IUDs have a very small risk of failure (less than 1 in 100 chance of pregnancy) *

Yes No

I understand that there is a 1 in 1000 risk of perforation of the womb at the time of insertion *

Yes No

I understand that there is a 1 in 20 chance of the IUD falling out *

Yes No

I understand that there is a 1 in 100 risk of infection in the first few weeks *

Yes No

I understand that the IUD will not protect against sexually transmitted infections and condoms in additional are recommended for this if for example I have a new partner *

Yes No

I know that a hormonal IUD will make my periods much lighter but can cause erratic bleeding and spotting in the first few months *

Yes No

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