Coil Fitting - Brim

For those considering a coil (IUD/IUS)

Your Details

If you are considering a coil (IUD/IUS) for contraception, please complete this form and submit at least two working days prior to your coil fitting appointment.

Name *

Date of Birth *

Phone Number *

Email Address

Please enter the date of your appointment *

Preparing for insertion of a coil

For intrauterine device (copper IUD) or an Intrauterine system (Mirena IUS)

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Which of the following applies to you? *

I have watched the video IUD/IUS (contraceptive coil) (8 mins, copyright NHS Lothian 2017) accessible via this website or Youtube

I have read the information on IUD/IUS on the NHS website This can be accessed via the links on our contraception page.

I already have an IUD or IUS and I am familiar with the method

Do you understand that no method is 100% effective and that the IUD/IUS has a very small risk of failure (less than 1 in 100 chance of pregnancy)? *

Yes No

Do you understand that there is a 1 in 1,000 risk of perforation of the womb at the time of insertion of the device (higher in the 4 months after childbirth and when breast feeding)? *

Yes No

Do you understand that there is a small risk of infection (1 in 100) in the first few weeks following insertion of a device? *

Yes No

Do you understand that there is a 1 in 20 chance of the device falling out? *

Yes No

Do you understand that the IUD/IUS will not protect against sexually transmitted infections (condoms are recommended if. for example, you have a new partner)? *

Yes No

Do you understand that if you are attending for a removal and refit of an IUD/IUS that you need to use additional contracption for 7 days before the procedure? *

Yes No

Do you understand that a Mirena coil (IUS) will make your periods much lighter but causes much more erratic bleeding and spotting in the first few months of use? *

Yes No

Do you understand that a copper coil (IUD) might make your periods heavier, longer and more painful? *

Yes No

I understand that it is not safe to insert an IUD/IUS if I might be pregnant. *

I understand

I do not understand

I might be pregnant

Are you using an effective method of contraception? *

Yes No

Have you had any issues with your contraception since your last period (eg burst condom, missed pill, IUD overdue for change)? *

Yes No

Have you had unprotected sex (or used withdrawal) since your last period? *

Yes No

Are you at risk of sexually transmitted infection (eg do you have a new partner)? *

Yes No

Have you been tested recently for chlamydia/gonorrhoea? *

Yes No

Please confirm the day of the appointment you will have had breakfast/lunch/tea. A pain killer can be taken around an hour in advance of your appointment *

I can confirm that I will have eaten prior to my appointment

IF YOU ALREADY HAVE A COIL AND ARE DUE FOR THIS TO BE CHANGED YOU MUST EITHER ABSTAIN FROM INTERCOURSE FOR 7 DAYS PRIOR TO THE APPOINTMENT OR USE CONDOMS. *

I understand

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the The Brimington Surgery website

Coil Fitting - Brim

Coil Fitting - Brim

Further Information