Reception: Pessary Change

Please complete this form if you would like to request a vaginal pessary change. Reception will contact you to arrange a convenient time to visit the surgery.

A vaginal pessary is a device made of rubber (latex) or silicone is inserted into the vagina and left in place to support the vaginal walls and pelvic organs.

Vaginal pessaries allow you to get pregnant in the future. They can be used to ease the symptoms of moderate or severe prolapses and are a good option if you cannot or would prefer not to have surgery.

Vaginal pessaries come in different shapes and sizes depending on your need. The most common is called a ring pessary.

You may need to try a few different types and sizes to find the one that works best for you.

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 3 working days to complete. Please DO NOT call before 3 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.

Reception: Pessary Change

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Who fitted your last pessary?

If other please state:

Any unpleasant smelling vaginal discharge?

Can you remember when this was?

Have you experienced any of the side effects listed below? (Please select as many as apply)

No side effects experienced

Unusual vaginal discharge

Vaginal irritation or discomfort

Vaginal bleeding

New incontinence of urine

Urinary tract infections (UTIs)

Interference with sex

Any vaginal bleeding?

Do you have a pessary to bring to your appointment?

If you do not have a pessary already please indicate below which chemist you would like us to send the prescription to.

The pessary can then be collected prior to your appointment and brought with you.

Which chemist would you like to collect your prescription from?

Smoking Status:

And a couple of final questions to keep our records up to date

Alcohol Consumption:

I confirm I am happy to be contacted by the surgery (text or call) on the number provided to arrange a convenient time to change my pessary.

Thank you for completing this form

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend your appointment at the surgery. Instead cancel your appointment and self-isolate for 7 days. Visit out Coronavirus page for more information. https://www.clmp.org.uk/Information-Zone/Coronavirus-Navigation-Hub

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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.