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Pre-Coil Questionnaire

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Personal Details

Please double check you've entered the correct email address

May be used to identify you

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Contraception Questions

Do you have an existing coil in situ?: *

What do you use the coil for?: *

Is there any chance you might be pregnant?: *

Do you require another form of contraception prior to coil fit?: *

Have you been given this contraception?: *

Are you sexually active?: *

Have you had a new sexual partner in the last 12 months?: *

Have you had more than one sexual partner in the last 12 months?: *

Has your regular sexual partner had other sexual partners?:

Do you have a history of STIs?: *

Have you attended surgery as a previous contact of STI?: *

Do you have a history of alcohol or substance misuse?: *

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Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Care Quality Commission
Overall Rating: Requires improvement

Heysham Primary Care Centre
Middleton Way
Heysham
LA3 2LE

Telephone: 01524 235 900

Morecambe Health Centre
Hanover Street
Morecambe
LA4 5LY

Telephone: 01524 235 900

West End Medical Practice
1 Heysham Road
Morecambe
LA3 1DA

Telephone: 01524 235 900

York Bridge Surgery
5 James Street
Morecambe
LA4 5TE

Telephone: 01524 235 900

Westgate Medical Practice
Braddon Close
Westgate
LA4 4UZ

Telephone: 01524 235 900