Patient Self-Referral Form

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All questions marked with a * are mandatory

Do you require assistance from a clinician or need to order a prescription?: *

This form is not for clinical purposes

 How to get clinical help and advice

 How to get a prescription

 What to do when we are closed

If you feel that your condition is life threatening please call 999

You are unable to continue using this contact form: *
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Personal Details

Please complete this form to refer yourself to our coil and/or pessary service. All submissions are triaged by a clinician before an appointment is offered. This service is only available to registered patients at Central Uxbridge Surgery.

Please double check you've entered the correct email address
May be used to identify you
Security and Eligibility
Are you currently registered at Central Uxbridge Surgery?: *

You are not eligible for this service.

Preferred contact method for appointment booking: *
Do you require an interpreter?: *
Reason for Referral (please select all that apply)
What service are you requesting?:
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Coil (IUD/IUS) Related Questions. Complete this section if referring for coil fitting, removal, or advice.
Have you had a coil fitted before?: *
Reason for coil request: *
Have you discussed this request with a GP or nurse previously?: *
Do you have any known allergies to copper, nickel, latex, or local anaesthetic?: *
Are you currently pregnant or think you may be pregnant?: *
Do you currently have any unusual vaginal bleeding, discharge, or pain?: *
Pessary Fitting/Review Questions. Complete this section if referring for a pessary fitting or review.
Have you been diagnosed with a vaginal prolapse before?: *
Are you currently using a pessary?: *
Do you experience:
Are you post-menopausal?: *
Are you currently using vaginal oestrogen cream/pessary?:
Medical Background
Do you have any of the following conditions?:
Are you currently taking any regular medications?: *
Do you have any mobility or accessibility needs for your appointment?:
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Consent and Declaration

Privacy Consent

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