Please complete this form to request the copper IUS implant 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’ll work as contraception until after the menopause when contraception isn’t needed

Please click the link below for more information on the Mirena coil

Mirena Coil

Please use format day/month/year e.g. 12/05/1979
Enter Email
One of our clinicians will contact you on this number in the next few days.

Please ensure you answer all questions.

Do you have any medical problems? *
Any medications? *
Any allergies? *
Have you had any irregular bleeding? *
Any bleeding after sex? *
Any bleeding between periods? *
Do you think you could be pregnant? *
What do you use for contraception at the moment? *
The doctor has explained I am to have the Mirena fitted for the following reasons. *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.