Please complete this form to ensure that we can fit your coil now that an appointment has been booked. It will also remind you of some important information about having a coil fitted. Select Yes or No to confirm that you have understood and are not aware of any reason why it might not be appropriate to proceed. If the checklist is not returned at least two working days prior to your appointment, your appointment may be cancelled. Please also complete the questions at the end. 

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Home address Required
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Are you under investigation for a gynaecological problem, on a waiting list to be seen by the gynaecology team and/or have you been recommended to have a hormonal IUS fitted for non-contraception purposes? Required
Are you requesting an IUD to manage heavy menstrual bleeding or as part of HRT? Required
Have you read the information on www.nhs.uk/contraception/methods-of-contraception webpage or do you already have an IUD and are you therefore familiar with this contraception method? Required
Are you using an effective method of contraception and can you confirm that you have not experienced a burst condom, missed pills, or other pregnancy risk since your last period? Required
Are you having unprotected sex (or using the withdrawal method) whilst you are waiting for a coil to be fitted? Required
Do you understand that it is not safe to insert an IUD if you might be pregnant? Required
Will you ensure that you have eaten a meal or light snack before your appointment, and consider rearranging if you are fasting? Required
You are advised to take an over-the-counter painkiller 30 to 60 minutes before your appointment. Please confirm that you have read this advice. Required
Are you aware that an IUD is more than 99 per cent effective (less than 1 in 100 chance of pregnancy) and that should a pregnancy occur, there is an increased risk of an ectopic pregnancy? Required
There is a very small risk (1 in 1,000) that the IUD might scrape or perforate your womb or cervix when it is put in. If this does happen, the device may have to be removed surgically. Please confirm that you are aware of this small risk. Required
There is a 1 in 20 chance of the device falling out. Please confirm that you have been made aware of this. Required
Do you accept that there is a small risk of infection (1 in 100) in the first 20 days after the coil fit? Required
Are you aware that a copper IUD may make periods slightly heavier, longer and more painful? Required
A hormone IUD may make your periods lighter or absent. Are you aware of this? Required

Only complete if you currently have an IUD in place.

Please confirm that you are aware that you should not have sex in the week before the appointment.
Please confirm that your current coil is within the licence date so still working OR if it is out of date that you have been using another form of contraception/not had sex for one month prior to the coil fit.
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You must agree before submitting.