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Sexual Health - IUCD fitting form

It is essential that this form is filled out prior to your GP booking you into a IUCD fitting appointment. Once this form has been completed, one of our members of staff will be in touch to get you booked in. Should you have any queries or issues, please give us a call on 0161 368 5426 


What type of referral are you making?
What contraception are you currently using?
Do you need an interpreter at the face to face appointment?
Do you currenly have any medical conditions?
Are you taking any medication that you have been prescribed or bought over the counter?
Do you think you might be pregnant?
Are you breastfeeding?
Do you have any drug or othe allergies? (Including peanut, soya or lactose)
Was the sex..
Have you had any new sexual partners in the last 3 months?
Are any of the following applicable to you in the last 3 months?
Are you currenly or have you ever experienced any of the below?

Thank you for submitting all required information.!

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