Coil insertion/replacement form

Long-acting contraception can provide a safe and effective method of contraception.

The contraceptive implant is a small rod sited in the upper arm which provides contraception for up to 3 years.

More information can be found on the NHS UK website.

If you are considering using an implant, or would like to have a current implant replaced or removed please:

Please fill in as much information as possible to help us arrange your appointment efficiently.

Some of this information will already be included in your medical notes but this is a good opportunity to update any changes.

Step 1 of 4

Date of Birth
If you would like a hormonal coil inserted or replaced is this for (please select all that apply)?
If you currently have an implant, what date is the replacement due?
If you currently have a coil, what date is the replacement due?

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