Conway Road Medical Practice

0161 973 1151

Coil/Implant form

If you have been advised by the surgery to do so please submit this form.

Please complete the checklist to ensure that we are able to fit your coil (Copper Coil IUD or Mirena Coil IUS) at your booked appointment.

This checklist will also provide you with some important information about having a coil fitted. If you have any questions please contact the practice.

Please watch a handy You Tube video to help you know what to expect: https://youtu.be/XHRYE2FsXmc

  • DD slash MM slash YYYY

  • Please complete the checklist below to ensure that we are able to fit your coil (Copper Coil - IUD or Mirena Coil IUS) at your booked appointment.

    ๐“๐ก๐ข๐ฌ ๐œ๐ก๐ž๐œ๐ค๐ฅ๐ข๐ฌ๐ญ ๐ฐ๐ข๐ฅ๐ฅ ๐š๐ฅ๐ฌ๐จ ๐ฉ๐ซ๐จ๐ฏ๐ข๐๐ž ๐ฒ๐จ๐ฎ ๐ฐ๐ข๐ญ๐ก ๐ฌ๐จ๐ฆ๐ž ๐ข๐ฆ๐ฉ๐จ๐ซ๐ญ๐š๐ง๐ญ ๐ข๐ง๐Ÿ๐จ๐ซ๐ฆ๐š๐ญ๐ข๐จ๐ง ๐š๐›๐จ๐ฎ๐ญ ๐ก๐š๐ฏ๐ข๐ง๐  ๐š ๐œ๐จ๐ข๐ฅ/๐ข๐ฆ๐ฉ๐ฅ๐š๐ง๐ญ ๐Ÿ๐ข๐ญ๐ญ๐ž๐.
  • Please tick the boxes to confirm that you have understood and are happy to consent to having a coil fitted:
  • DD slash MM slash YYYY

Date published: 26th April, 2021
Date last updated: 27th May, 2022