LARC – Self Referral Form Your DetailsName First Last Date of birth Day Month Year Address Street Address Address Line 2 City Postcode Telephone NumberNHS Number (If Known) OptionalReason For Referral To start new contraception Replacement – Existing LARC due to expire or causing issues Complications – Side effects, issues with current LARC What type of LARC would you prefer? Contraceptive Implant (sub dermal implant in the arm) IUS (coil) IUD (coil) Which practice are you registered with? Castle Donington Surgery Castle Medical Group Measham Medical Unit Markfield Medical Centre Whitwick Road Surgery Long Lane Surgery Dr Patel & Dr Tailor Broom Leys Surgery Hugglescote Surgery Manor House Surgery Dr Virmani & Dr Bedi Ibstock & Barlestone I’m registered with a different practice Please tell us which practice you’re registered with:What days can you attend for an appointment? Weekdays Saturdays What is your current contraceptive method? None Implant Coil The contraceptive pill Other If other, please clarify your current contraceptive method:How long have you been taking / on this?Do you consent to sharing your electronic health records? Yes No Please record any relevant Medical History (Please include any known allergies, menstrual history, contraindications to hormonal contraception, or other relevant conditions:
