Family Planning Consent Form

Preparing for insertion of an intrauterine device (copper coil) or an intrauterine system (mirena/Jaydess/kyleena).

  • If you are eligible for the coil, we would like to make the process as straightforward as possible on the day of your appointment.
  • If you have any questions, please book a telephone appointment.

Once you have completed the consent form below, it will be attached your medical record and you will be added to a waiting list.

  • Reception will contact you when an appointment becomes available.
  • If you have not heard from the surgery in 3 months, please contact us.
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Select Your Surgery
Personal Details
Please double check you've entered the correct email address
May be used to identify you

Please tick the boxes to confirm you have understood and agreed to the following:

Signature

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.

 
Previous Page  
Processing

Page you are trying to access does not exist.