Reception: Coil removal form

A coil must be removed by a trained doctor or nurse at the surgery.

If you are having your coil removed and do not want any risk of pregnancy please avoid sex for 7 days before your appointment to have it removed. This is because sperm can survive for up to a week.

If you wish to use another form of contraception following the removal of your coil please state this below in the form. You may wish to start an alternative form of contraception before the coil is removed to ensure that it is effective immediately.

If you wish to have your coil removed and replaced with another, please do NOT complete this form. Instead complete the coil replacement form below:

Coil replacement

If you have had a copper coil fitted for emergency contraception and then want to have it removed, the coil will need to be retained until pregnancy has been ruled out. This could be after the start of your next period or after you have had a negative pregnancy test 3 weeks after the episode of unprotected sex that prompted the coil fit as emergency contraception.

If you are planning to become pregnant please review the information found in this link and consider stopping smoking, reducing alcohol intake and making sure to use folic acid.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Details

Full Name:

Date of Birth:

Contact number (Preferably mobile):

Information

Why would you like the coil removed?This may be because it is no longer needed, you may want a different method of contraception or you may wish to try and conceive

Do you need alternative contraception and if so which type?If a coil or implant replacement is needed please complete the coil or implant replacement form. Link found above.

I understand that unless I abstain from sex or use alternative contraception for 7 days prior to my appointment there is a risk of pregnancy

Thank you for completing this form. It will be reviewed by our team and you will be contacted in due course.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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