Contraception including IUD Insertions

Oral contraceptive Pill check section

If you would like to request a repeat prescription of the contraceptive pill you are currently taking and you are due a review of this medicine, then please fill out the form below.

When you are taking the oral contraceptive pill, you need to have a review (including blood pressure and weight) at least every 12 months. You may be due a review sooner if you have recently started or changed your contraceptive pill.

If you are interested in finding out about Long acting reversible contraception (LARC) please read the information available via this link. If you would like to discuss the option of LARC further with a clinician, please request a telephone call.

The information will be sent to the practice team and your request will be processed within 48 hours.

Click here to complete Oral contraceptive Pill check form

Your Details

Required field(s) are indicated by *
Date of Birth
This form is for the repeat prescription of the combined oral contraceptive pill (COC) and the progestogen only pill (POP) and, available if you are a current user of this method and have already been prescribed this method in the last 12 months
I understand that if there are any queries or there is additional information needed that this may require a direct communication with a health care professional

CONTRACEPTIVE PILL REVIEW

For online postal service for oral contraception, please see www.sexualhealth.cnwl.nhs.uk/order-form.
Please confirm that you have no new concerns about this pill (if you have new concerns/questions please book a telephone appointment to discuss further)
Have you started any new medication, including herbal medication e.g. St John’s wort, since we last issued you a prescription for the pill? (Please be aware that certain over the counter medicines and herbal remedies such as St Johns wort can reduce the efficiency of the pill. Please check with a health care professional if you have any concerns.
Have you been diagnosed with any new health conditions since we last issued you a prescription?
Smoking Status
Do you suffer from migraines with aura (aura is when there are specific warning signs just before the migraine begins, for example visual disturbance)?
Have you suffered from any irregular vaginal bleeding, bleeding between periods or bleeding after sex in the past 12 months?
Have you ever had a blood clot?
Have any of your immediate family ever had a blood clot?
Have you ever had breast cancer?
Have any of your immediate family ever had breast cancer?
Information about what to do if you miss a pill can be found on the Family Planning Association website. https://www.sexwise.org.uk/contraception/combined-pill-coc

YOUR MESEARMENTS

Consent

If at any time you have concerns about your medication then please book a telephone appointment with a health care professional, this can be the clinical pharmacist, nurse or GP.
I confirm that the information provided is accurate to the best of my knowledge

Contraceptive Implant

Contraceptive Implant Fitting Form

Please watch this video about the contraceptive implant.

If you would like to have a Contraceptive Implant fitted please fill in the online form: 

Click here to complete Contraception Implant fitting form

Contraception Implant Fitting Form

Your Details

Required field(s) are indicated by *
Date of Birth
I confirm that I have watched the video on the contraceptive implant Or read the leaflets Or already have an implant and am familiar with the method
I have been using contraceptive methods and will continue to do so until the day of fitting so that there isn’t a risk of pregnancy
I am aware of the hormonal effects of the contraceptive implant and that irregular bleeding or no bleeding is common. I am also aware that headaches/ nausea/ mood swings and acne are less common side effects
I am aware that the fitting process will require the use of local anaesthetic and that there may be some bruising/ tenderness and slight swelling after the procedure
I am aware that there is a small risk of infection at the insertion/ removal site ( less than 0.5%)
I am aware that the risk of pregnancy is very low but to do a pregnancy test and inform the doctor if pregnant If the implant is still inserted.
I am aware that the implant when removed will require a further cut to remove the implant with local anaesthetic
Are you on any medications that may affect the implant – ( Anti- Retrovirals / Anti epileptic medication / Mood stabilisers / )
I am aware that as soon as the implant is removed there is a risk of pregnancy
I am aware that I may need to use additional contraception after fitting dependant on my method of contraception currently
I am aware that I will seek medical advice if worsening pain or fever in or around the site of insertion or if I cannot feel the implant in the future.

Contraceptive Implant Removal Form

If you would like to have a Contraceptive Implant removed please fill in the online form: 

Click here to complete Contraceptive implant removal form.

Contraceptive Implant Removal Form

Your Details

Required field(s) are indicated by *
Date of Birth
I am aware that as soon as the implant is removed there is a risk of pregnancy
I am aware that I may need to use additional contraception after removal if required
I am aware that I may need to use additional contraception after removal if required

Contraceptive implant removal form.

Intrauterine Contraception (coil) Fitting

Preparing For the Insertion of an Intrauterine Device (Copper IUD) or an Intrauterine System (IUS) at The City Road Medical centre.

We are keen to make your clinic visit as straightforward and streamlined as possible.  It is important that you have done the following:

  1. Watched the information about intrauterine contraception video.
  2. Read the information advising you about what contraception you need before having a coil fitted page.
  3. Completed the Intrauterine contraception fitting form. (See below)

Click here to complete Intrauterine contraception fitting form.

Intrauterine contraceptive fitting form

Section Break

Name
MM slash DD slash YYYY
I have watched the video on IUD/IUS or read the leaflets or I already have an IUD/IUS and am familiar with the method
I am using an effective method of contraception and haven’t had any problems (e.g burst condom, missed pills, IUD overdue for change). I have not had unprotected sex (or used withdrawal) since my last period.
I confirm that I have read the page on Contraception before IUC fitting
I understand that it is not safe to insert an IUD/IUS if I might be pregnant.
I will make sure that I have had a light meal on the day of the appointment. A painkiller can be taken around an hour in advance.
I am not at risk of sexually transmitted infection (eg I do not have a new partner) or I have been tested recently for chlamydia / gonorrhoea. I will discuss this with the doctor if I am concerned.
I understand that no method is 100% effective and that the IUD/IUS has a very small risk of failure (less than 1 in 100 chance of pregnancy).
I understand that there is a 1 in 1000 risk of perforation of the womb at the time of insertion of the device. If I am breastfeeding this risk is 1 in 200
I understand that there is a 1 in 20 chance of the device falling out.
I understand that the IUD/IUS will not protect against sexually transmitted infections and condoms in addition are recommended for this if for example I have a new partner.
I understand that there is a small risk of infection (1 in 100) in the first few weeks following insertion of a device.
I know that a copper IUD will make my periods slightly heavier, longer and more painful.
I know that an IUS will make my periods much lighter but causes erratic bleeding and spotting in the first few months of use.
I will understand that there may be some bleeding and pain after the procedure and will bring sanitary protection with me

Once you have done the above call the practice on 020 7336 8170 or email us at Cityroadmedicalcentre@nhs.net to request an appointment for a coil fitting appointment with Dr Katie Coleman.

If you wish to discuss intrauterine contraception further, please book a telephone appointment with Dr Katie Coleman.

Intrauterine Contraception Removal

Removal of IUD or IUS can be done in a 10 minute face to face consultation with a health care professional.

It is important, in order to avoid risk of pregnancy after removal of your device that you abstain from intercourse for 7 days prior to your appointment.

Click here to complete Intrauterine contraceptive removal form

Intrauterine contraceptive removal form

Your Details

Required field(s) are indicated by *
Date of Birth

ONLINE REQUEST FOR BOOKING APPOINTMENT FOR INTRAUTERINE CONTRACEPTION REMOVAL

Required field(s) are indicated by *
I confirm that I have read the information about removal
I am aware that I am a risk of pregnancy once the coil is removed ( unless removed due to menopause )
I am aware that there occasionally a removal may be unsuccessful and I can be referred to the specialist clinic for further management