Coil and Implant Waiting List Request

If you would like to be put on the waiting list for coil insertion, coil exchange,
implant insertion, implant exchange or implant removal, please fill in this form.

For coil removal, you do not need to fill in this form. Please book a routine face to face appointment with Dr Mandlik, Dr Eisner or Dr Gubert.

Once you have submitted this form, we will send you a text message to confirm you have been added to our waiting list.

If you do not receive a text message confirming this in the following 10 days of submitting this form, please let us know.

Coil and Implant Waiting List Request

Section

Which procedure would you like? (If you are not sure which procedure you would like, please book a telephone appointment with one of our clinicians to discuss) *

Please use a condom or avoid sex for 7 days before a coil exchange. Sperm lives for up to 7 days. If any sperm is present, there will be a risk of pregnancy if for whatever reason we can not fit a new coil after removing the old one (eg due to spasm of the cervix).

Have you ever had a contraceptive device (coil or implant) before? *
Do you require the coil or implant for contraceptive purposes? *
Are you looking to have a coil inserted as part of peri-menopausal HRT treatment? *
Have you had a recent sexual health screen including chlamydia and gonorrhoea testing? *

If your sexual health screen is not up to date, you can request a sexual health screen by post by visiting www.sh24.org.uk.

You can also search for sexual health clinics near you by visiting www.nhs.uk/service-search/sexual-health/find-a-sexual-health-clinic

Are you currently using contraception? *
Please choose one or more of the below that you are currently using:
Please use this date format (DD/MM/YYYY)
Do you have periods at the moment? *
Please use this date format: DD/MM/YYYY
Have you ever been pregnant? *
Have you had a baby in the last 6 months? *
Are you breastfeeding?
Please use this date format: DD/MM/YYYY

Fitting a contraceptive coil in the first 6 months after delivery in a breastfeeding woman is associated with a roughly 11 fold higher risk of perforating the womb. As a result, Dr Gubert encourages breastfeeding women to use alternative contraception in the 6 months after delivery.

Please book a telephone appointment if you would like to discuss further.

Are you on any other medications? *

Some people find it helpful to listen to music during the procedure and Dr Gubert encourages you to bring whatever you think would be helpful.

Please use a condom or avoid sex for 7 days before a coil exchange. Sperm lives for up to 7 days. If any sperm is present, there will be a risk of pregnancy if for whatever reason we can not fit a new coil after removing the old one (e.g. due to spasm of the cervix).