Contraceptive Appointment Form

Use this form to register your interest in our Contraceptive Clinic. You must be a patient to utilise this service. Once your form is completed our team will contact you to schedule an appointment.

Please note that this form should NOT be used by:

  • Patients requesting the contraceptive pill for the first time, as you will need a doctor’s appointment before this can prescribed.
  • Patients that have recently registered with the surgery but are yet to have a prescription from us for the contraceptive pill. New patients will need to have a medication review appointment before this can be safely prescribed.

Please also note that we do not offer the ‘morning after’ pill, e.g. Levonelle or ellaOne.

Contraceptive Appointment Form

Patient Details

Please use date format DD/MM/YYYY

Requirements/Problems

Consultation *
Pain/Unusual symptoms *
Vaginal coil fitting *
Vaginal coil exchange *
Vaginal coil removal *
Vaginal coil check *
Arm implant fitting *
Arm implant exchange *
Arm implant removal *