Long-Acting Contraception Self-Referral

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All questions marked with a * are mandatory

If you live in City and Hackney you can self-refer to The Wick Health Centre for the service which also includes removals, you don't need to be permanently registered with us.

  • By completing this form you will be temporarily registered with this GP Surgery, this will not affect your current registration your own GP Surgery
  • All information collected on this form and during any appointments offered are confidential. however, your current GP Surgery will be notified once the procedure is complete.
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Information about your choices

Please take the time to read the information below to allow you to make an informed decision about your needs.

You will be given the opportunity to ask any questions you may have at your telephone assessment.

Implant

Hormonal coils

We offer 2 different hormonal coils

  • Jaydess
    • lowest dose hormonal coil
    • used for 3 years.
  • Mirena
    • low dose coil
    • newly licensed for 8 year use for contraception

Non-hormonal coil

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Personal Details
Please double check you've entered the correct mobile number
Please double check you've entered the correct email address
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Contraception
Do you require a: *
Your choice of Contraception: *
Are you currently using any other type of contraception: *
Pill, patch, ring, injection
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Assessment
Have you recently had sexual intercourse without using a condom: *
Have you recently given birth: *
Are you currently breastfeeding: *
Do you have any vaginal bleeding that you’re concerned isn’t normal?: *
Have you discussed this with a healthcare professional already: *

Please book an appointment with a GP or specialist Nurse, your referral may be rejected.

You cannot continue with this form: *
Have you recently had any sexual health tests: *
Are you being seen at the hospital because of an abnormal smear result: *
Do you have a history of, or do you currently have breast cancer: *
Do you have any history of heart disease or a stroke: *
Do you have any history of liver disease: *
Do you have any issues with your immune system or take any medications that may cause you to be immunocompromised: *
Do you have a history of fibroids (benign growths inside your womb): *
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Declaration

Privacy Consent

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Care Quality Commission
Rating: Good

The Wick Health Centre
10 Kenworthy Road
London
E9 5TD

Telephone: 020 8986 6341

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