Post-Natal Community LARC Service Referral Request Please select the relevant option: Patient Registered with Birmingham GP Patient Registered with Solihull GP Other Name First Last Date of birth DD slash MM slash YYYY AddressThe one used to register with your GP Postcode What is your sex?As recorded on your medical record Male Female Other Phone numberEmailAnyone else with access to your email account may see responses sent to you Enter Email Confirm Email NHS Number (if known): OptionalGeneral InformationDate of delivery: OptionalType of delivery (vaginal/cesarean): OptionalComplications during delivery (if any): OptionalCurrent breastfeeding status: OptionalMenstrual history (last menstrual period): OptionalMedical HistoryGeneral health status (ongoing medical conditions or recent illnesses, especially cardiac conditions or epilepsy): OptionalAllergies and sensitivities: OptionalCurrent medications: OptionalPrevious contraceptive methods used: OptionalPrevious gynaecological surgeries or gynaecological problems: OptionalSTI screening status / previous STI infection: OptionalUterine abnormalities or fibroids (if known): OptionalPregnancy and Postnatal HistoryGravidity (number of pregnancies): OptionalParity (number of deliveries): OptionalComplications during pregnancy/postpartum (if any): OptionalPatient Request, Counselling and EducationPatient is requesting to have: Implant Optional IUD Optional Hormonal LNG-IUD Optional Information provided on Intrauterine Devices (for both hormone and non-hormone coils): OptionalAlternative contraceptive options discussed: OptionalAlternative contraceptive option patient has chosen now: POP Optional DMPA Optional Condoms Optional Information and ConsentConsent Patient consents to receive a telephone consultation to discuss their contraceptive needs Patient understands that Yardley Green Medical Centre, an Umbrella service partner, reserves the right to make a decision towards onward referral for medical reasons picked up during counselling Patient understands that an Umbrella leaflet can be provided on Implants / Intrauterine Devices Referral DetailsReferring GP or Midwife: OptionalReferral date: OptionalPreferred appointment date/time (if requested): Optional