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Bournbrook Varsity Medical Centre , 1a Alton Road , 0121 472 0129

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Contraceptive Services Only Registration Form

Last Updated: 06/05/2022

Contraceptive Services Only Registration Form

Complete this form to register for contraceptive only services. Available only if you are living in Birmingham or Solihull. Upon receipt our admin team will contact you to book your initial telephone consultation with one of our contraceptive specialist doctors.

Title *

Mrs

Miss

Other

Office use only : code 9bE4

Forename *

Surname *

Date of Birth *

NHS Number

Address *

Mobile Number

Phone Number

Email address

Name of Regular GP Practice *

Service Required *

Coil Fit

Coil Removal

Coil Change

Implant Fit

Implant Removal

Implant Change

For Implant removals or changes - Have you had your current implant for 6 months or longer?

Yes No

Please give any details regarding your current contraceptive method & reason for appointment. This will help the doctor to prepare for your telephone consultation:

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