Post-partum coil referral

Please select the relevant option: *

Patient Registered with Birmingham GP

Patient Registered with Solihull GP

Other

Please specify GP location: *

NHS Number:

If known

General Information

Date of delivery:

Type of delivery (vaginal/cesarean):

Complications during delivery (if any):

Current breastfeeding status:

Menstrual history (last menstrual period):

Medical History

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

Allergies and sensitivities:

Current medications:

Previous contraceptive methods used:

Previous gynaecological surgeries or gynaecological problems:

STI screening status / previous STI infection:

Uterine abnormalities or fibroids (if known):

Pregnancy and Postnatal History

Gravidity (number of pregnancies):

Parity (number of deliveries):

Complications during pregnancy/postpartum (if any):

Patient Request, Counselling and Education

Patient is requesting to have:

Implant

IUD

Hormonal LNG-IUD

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

Alternative contraceptive options discussed:

Alternative contraceptive option patient has chosen now:

POP

DMPA

Condoms

Information and Consent

Consent

Patient consents to pass on information and request to Yardley Green Medical Centre

Patient consents to receive a telephone consultation to discuss their contraceptive needs

Patient understands that Yardley Green Medical Centre, an Umbrella service partner, reserves the right to make a decision towards onward referral for medical reasons picked up during counselling

Patient understands that an Umbrella leaflet can be provided on Implants / Intrauterine Devices

Referral Details

Midwife’s name:

Referral date: