Rosehill clinic IUC (Coil) self-referral form

 

Your details

Note: Questions marked by * are mandatory






  Yes No
*This is a mandatory field. Can we text you on this number?
*This is a mandatory field. Can we leave a message on this number?





  No Yes, you will receive a phone call to discuss
*This is a mandatory field. Was your copper coil (IUD) fitted age 40 or over?
*This is a mandatory field. Was your hormonal coil (IUS) fitted age 45 or over?
*This is a mandatory field. Have you any past or current cardiovascular disease, epilepsy, pelvic infection, anatomical abnormality of the uterus e.g. bi –cornuate uterus, abnormal vaginal bleeding such as bleeding after sex or between periods.
*This is a mandatory field. Have you had any treatment to your cervix after an abnormal smear test?
*This is a mandatory field. Have you had any problems having a Coil fitted previously? (fits or fainting)

 

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To order an online testing kit, please visit: https://www.shl.uk/ 

If you do not live in a participating borough or have questions please call 020 8296 3910.

If you have had sex which may have put you at risk of an infection (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.