Hormonal Coil

Essential Information About Coil Appointment

If this is a new coil or your coil/contraceptive method has expired, you must use adequate contraception for 21 days (3 weeks) prior to the appointment. You will be asked to confirm this on the day of your appointment and if you have had any unprotected sexual intercourse in the 3 weeks prior, then the coil cannot be inserted as we would be unable to rule out a potential early pregnancy.

Contraception can include barrier methods (e.g. condoms), contraceptive pills, a depot injection given less than 12 weeks ago, an implant that remains in date, or a coil that remains in date.

Please note: Hormonal coils such as Levosert and Mirena can now be used for 8 years for contraception. If they are used as part of Hormone Replacement Therapy (HRT), they must be changed at 5 years.

Please complete this form to request the Hormonal IUS through your GP practice

An IUS is a small plastic device that’s put into your uterus (womb) and releases a progestogen hormone. This is similar to the natural progesterone produced by the ovaries.

The IUS works as contraception for three or five years, depending on the type.

There are different types and sizes, with different amounts of the progestogen hormone.

If you’re aged over 45 when a particular type of IUS (Mirena) is fitted, it will work as contraception until after the menopause, when contraception is no longer needed.

For more information, please visit the NHS website: Mirena IUS (coil)

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I have read an fully understand the side effects, effectiveness and complications of the implant.

I am aware that I need to use adequate contraception until device fitted.

I agree that I have been informed of both the benefits and the risks of using the Mirena

I acknowledge that the doctor has explained the proposed procedure. I understand the risks of the procedure and the likely outcome. The doctor has explained other relevant contraceptive options and their associated risks. I was able to ask questions and raise concerns with the doctor, which have been discussed to my satisfaction.

I hereby request to have the procedure and authorise Dr and such assistants to perform the insertion of the Mirena coil.

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Hormonal Coil Request

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