Request for IUC (Mirena & Copper Coil) Questionnaire

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Intra Uterine Contraception (IUC) is very safe and very effective contraception. The IUS (Mirena) also reduces heavy mentstrual blood flow and can be used as a component of HRT (hormone replacement therapy).

In order that we offer the best and safest service and to ensure our appointments are used optimally, Please fill in the below questionnaire and read the information sheet "Your Intrauterine Contraceptive fitting" which can be found on our website using the link below:-

Once we have received the form, one of our receptionists will be in touch within one week to book your IUC appointment. Please contact us if you dont hear anything within a week.

It is really important that you are not pregnant at the time of IUC fitting.

Unfortunately condoms do not provide sufficient contraceptive effectiveness to guarantee this.

Is there a risk you may be pregnant?: *

Please continue using your contraception until your IUC is fitted and for 7 days afterwards

For your safety, we must ask some sensitive questions to assess the risks

Is there a current risk of a sexually transmitted infection (STI) ?: *

Are you aged 25 or less?: *

Have you had a new sexual partner in the last 12 months? : *

Have you had more than one sexual partner in the last 12 months?: *

Does your sexual partner have other sexual partners?: *

Have you ever had any sexually transmitted infections?: *

Have you been in contact with anyone who has had a sexually transmitted infection (STI)?: *

Have you had any new vaginal discharge?: *

If the answers to any of the infection questions are YES, please visit the practice and ask the receptionist for a self administered vaginal swab and instructions.

You can then do the swab in the practice toilets or in the comfort of your own home and once complete please hand in at the reception desk before 3pm.

The results will be sent as a text to your mobile phone so please ensure we have the correct and up-to-date mobile number on your medical records. Your result will be sent by text to your mobile and it will state "your chlamydia and gonorrhoea test is ........."

Are you experiencing abnormal vaginal bleeding? By that we mean bleeding between periods, bleeding after sex or new and uninvestigated bleeding that is heavier or irregular: *

If Yes, Please make an appointment with the family planning nurse or doctor to discuss this before the IUC appointment is booked. You can do this by booking an appointment through the telephone or on patient access.

Have you ever been diagnosed with fibroids? nb this could make an IUC fit more difficult. We could try to fit the IUC but we may not succeed: *

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This form collects personal and medical informanot tion 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.

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Request for IUC (Mirena & Copper Coil) Questionnaire

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