Self-referral to Contraceptive Coil Fit Clinic Self-referral to Contraceptive Coil Fit Clinic "*" indicates required fields Exclusion Criteria: Under 18. Undiagnosed vaginal bleeding. Severe anaemia. Pregnancy. Current or recently treated STI. HIV. Postpartum or post termination sepsis. Gestational trophoblastic neoplasm. Cervical, Uterine, Genital malignancy. Current or recently treated Pelvic Inflammatory Disease. Pelvic TB. Patient Name* First Name Last Name Patient D.O.B* DD slash MM slash YYYY Patient Address* Street Address Address Line 2 City State / Province / Region Post Code Patient NHS number*Patient contact number*Ethnicity OptionalRegistered GP Practice*Type of coil requested*Current contraceptive methods*Reason for coil fit Contraception Optional Heavy periods Optional HRT Optional All/both Optional Phone OptionalThis field is for validation purposes and should be left unchanged.
