IUC Self Referral Form

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Your Details

Please note: Questions marked by * are mandatory

Do you require an interpreter? : *
What type of Coil would you like?: *
What contraception are you currently on? (Please Tick): *
Have you missed or been late for any pills/patches/ring/Injection in the last 3 months?:
Have you had any pregnancies? : *
Was the birth:
Are you breastfeeding?:
Medical Conditions
Do you have any of the following illnesses or medical conditions:
were there any complications: *
Is your CD4 count more than 200 cells/mm3 : *
Are you on any medication? : *
Was your copper coil (IUD) fitted age 40 or over?: *
Was your hormonal coil (IUS) fitted age 45 or over?: *
Have you any past or current cardiovascular disease, epilepsy, pelvic infection, organ transplant, anatomical abnormality of the uterus e.g. bi –cornuate uterus, fibroids, abnormal vaginal bleeding such as bleeding after sex or between periods.: *
Have you given birth or had an abortion and have an infection in your womb/uterus? : *
Have you had any problems having a Coil fitted previously? (fits or fainting) had to have it fitted under General anesthetic?: *

If you have ticked yes to certain health conditions you may receive a phone call to discuss this.

Have you had a negative test for chlamydia and gonorrhea in the past 3 months?: *

If you have had a new partner since then please retest.

You are recommended to do a test to ensure you do not have a sexually transmitted infection. 


You will receive a text/call with details of an appointment/ telephone appointment. 

To order an online sexual health testing kit, please visit Sexual Health London

If you have had sex which may have put you at risk of an infection or pregnancy (sex without condoms, new partners, partners with a known infection) the coil fitting may need to be postponed until you have tested for sexually transmitted infections and pregnancy has been ruled out.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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