lac-self-referral-form – Spring Hill Practice

By completing this form you will be temporarily registered with this GP Surgery, this will not affect your current registration your own GP Surgery

All information collected on this form and during any appointments offered are confidential. however, your current GP Surgery will be notified once the procedure is complete.

It is vital that all questions are completed as accurately as possible.

I understand that by completing this form I will be temporarily registered with this GP Surgery, this will not affect your current registration status with your own GP Surgery. *

I understand that my current GP Surgery will be notified once the procedure is complete. *

Please take the time to read the information below to allow you to make an informed decision about your needs.

You will be given the opportunity to ask any questions you may have at your telephone assessment.

Implant
Contraception Choices - Implant

Hormonal coils
Contraception Choices - Coil

Non hormonal coil
Contraception Choices - Non Hormonal Coil

We offer 2 different hormonal coils

Jaydess

lowest dose hormonal coil
used for 3 years.

Mirena

low dose coil
Newly licensed for 8 year use for contraception

Do you require a

Fitting Removal

Your choice of Contraception

Coil Implant

Are you currently using any other type of contraception

Yes No

When was the first day of your last period

Have you recently had sexual intercourse without using a condom

Yes No

Have you recently had sexual intercourse without using a condom: * Yes No Have you recently given birth:

Yes No

Are you currently breastfeeding:

Yes No

Do you have any vaginal bleeding that you’re concerned isn’t normal?:

Yes No

Have you recently had any sexual health tests:

Yes No

When did you have them:

I understand that I may be asked to have a sexual health test before attending *

Have you been treated for a sexually transmitted infection in the last 4 - 8 weeks:

When was this treated:

In what year was your last smear test (cervical cytology, pap)

Are you being seen at the hospital because of an abnormal smear result:

Yes No

Do you have a history of, or do you currently have breast cancer:

Yes No

Do you have any history of liver disease:

Yes No

Do you have any issues with your immune system or take any medications that may cause you to be immunocompromised:

Yes No

Do you have a history of fibroids (benign growths inside your womb):

Yes No

I understand that all procedure on this form have certain risks associated with its use and the procedure, as outlined in the information previously provided in this form, and I will have the opportunity to discussed this further in my assessment. *

All information provided is correct to the best of my knowledge. *

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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.

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

Long acting contraception self-referral form

Spring Hill Practice

GP Surgery

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