Post-partum coil referral

Please select the relevant option: *

Registered Patient

Non Registered Patient

NHS Number: *

Current GP Surgery Name: *

Date of delivery:

Type of delivery (vaginal/cesarean):

Complications during delivery (if any):

Current breastfeeding status:

Menstrual history (last menstrual period and regularity):

Allergies or sensitivities:

General health status (ongoing medical conditions or recent illnesses, especially cardiac conditions or epilepsy):

Previous gynaecological procedures:

Previous contraceptive methods used:

Current medications:

Any known contraindications for Intrauterine Device (IUD) use:

STI screening status / previous STI infection:

Cervical smear history (if needed we can do at the time of coil insertion at 12 weeks):

Uterine abnormalities or fibroids (if known):

Gravidity (number of pregnancies):

Parity (number of deliveries):

Gestational age (for current pregnancy):

Birth weight of baby:

Complications during pregnancy/postpartum (if any):

Information provided on Intrauterine Devices (for both hormone and non-hormone coils):

Alternative contraceptive options discussed:

Midwife’s name:

Referral date:

Preferred appointment date/time (if requested):

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