Coil Fitting Checklist and Consent

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

Please complete this 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.

Coil Fitting Checklist and Consent

Patient Details

Please use this date format: DD/MM/YYYY.

Consent

Please complete this 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.

Please tick the boxes to confirm that you have understood and are happy to consent to having a coil fitted:

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