Self-referral to Contraceptive Implant Fit Clinic Self-referral to Contraceptive Implant Fit Clinic "*" indicates required fields Facebook OptionalThis field is for validation purposes and should be left unchanged.Exclusion Criteria: Under 18. Undiagnosed vaginal bleeding. Pregnancy. Currently taking drugs for HIV, TB, or taking Carbamazepine. Current or previous history of breast cancer. Liver cirrhosis or liver cancer. 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*Current contraceptive methods*Sexually transmitted disease screening up to date. Yes Optional No Optional Not applicable Optional Interpreter required*YesNo
