Women’s Health Hub – Coil and Implant Referral Form

*Only for patients registered with a Kirkby GP surgery*

What is your Name?

What is your Date of Birth

Contact Details

Mobile Number 

E-mail address 

House/Flat number 
First line of address 
Second line of address
Third line of address 
Postcode 

What is the name of your GP practice?

Select one of these options: SelectWingate Medical CentreMillbrook Medical CentreDr Maassarani & PartnersSt Laurences Medical CentreMacmillan Surgery

Any disabilities we need to be aware of?  Please answer and confirm details: SelectYesNo
If yes, please provide details

Do you require an interpreter?: SelectYesNo
If yes, please state which language

Are you using any form of contraception currently? SelectYesNo
If yes, please state

Which type of appointment do you require? Select one of these options: SelectContraceptive Implant InsertionContraceptive Implant RemovalContraceptive Implant ReplacementCopper Coil InsertionCopper Coil RemovalCopper Coil ReplacementHormonal Coil InsertionHormonal Coil RemovalHormonal Coil Replacement

Why are you requesting the coil/implant? Select one of these options: SelectFor contraceptionTo help with periodsAs part of HRT

Send