Coil Fitting Appointment Questionnaire

Please complete this questionnaire before your coil fitting appointment.

Coil Fitting Appointment Questionnaire
Please use format day/month/year e.g. 12/05/1979
Coil Requested
Do you have a current coil?

Please continue with your current contraception for 1 week AFTER coil is fitted.

Result of last smear
Any previous treatment or surgery to cervix e.g. at colposcopy clinic?
Any Sexually Transmitted Infection in the past e.g. chlamydia, gonorrhoea?
New Sexual Partner in past 3 months?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.