Long Acting Contraception (LARC) Coil and Implant Self-Referral

 
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Confirmation

This referral form enables you to refer yourself for long acting contraception at Nightingale Practice.
Once your form is completed and received by the practice you will be contacted by phone to discuss your assessment and to book the procedure at the 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.

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Information about your choices

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

Hormonal coils

We offer 2 different hormonal coils

  • Mirena
    • low dose hormonal coil; licensed for 8 year use for contraception
  • Jaydess
    • lowest dose hormonal coil; licensed for 3 years for contraception.

Non hormonal coil

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Personal Details
Please double check you've entered the correct mobile number
Please double check you've entered the correct email address
Interpreter Needed:
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Contraception

Please select the type of contraception/procedure you require

Do you require a coil: *
Do you require an implant: *
Are you currently using any other type of contraception: *
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Assessment
Have you recently had sexual intercourse without using a condom: *
Have you recently given birth: *
Are you currently breastfeeding: *
Do you have any vaginal bleeding that you’re concerned isn’t normal?: *
Have you discussed this with a healthcare professional already: *

Please book an appointment with a GP or specialist Nurse, your referral may be rejected.

You cannot continue with this form: *
Have you recently had any sexual health tests:

Please arrange a sexual health screening using the below link:

Home STI testing, regular and emergency contraception

Have you been treated for a sexually transmitted infection in the last 4 - 8 weeks: *
Are you being seen at the hospital because of an abnormal smear result: *
Do you have a history of, or do you currently have breast cancer: *
Do you have any history of heart disease or a stroke: *
Do you have any history of liver disease: *
Do you have any issues with your immune system or take any medications that may cause you to be immunocompromised: *
Do you have a history of fibroids (benign growths inside your womb): *
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Declaration

Privacy Consent

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.

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Providing NHS Services

Contact

Nightingale Practice
10 Kenninghall Road
Clapton
London
E5 8BY

Telephone: 020 8985 8388

The Practice

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