IUD Booking Form - Willow Clinic

Skip to content

Willow Clinic

For Optimal Health

Home
Abortions
Birth Control
Vasectomy
Other Services
Info. for Clinicians
Resources
- Vulvodynia
- Our Research Program
Contact

IUD/Implant Booking Form

Do You Have a BC Care Card (PHN)? *

Yes
No

I will be paying privately for this visit *

I will be paying privately for this visit.

Medical Care Card # *

NAME - as on Medical Card: *

Preferred first Name:

Date of Birth / Day - Month - Year *//

Address: *

City *

Postal Code *

Phone Number (copy) *

Email *

Emergency contact Name *

Emergency Contact Phone Number *

Referring Doctor Name

Doctor's Phone Number

What type of IUD do you want?

Copper
Mirena
Kyleena
Implant (Nexplanon)
I'm not sure

Do you already have a prescription?

Yes
No

Message

If this IUD is for Emergency Contraception, don’t wait for us to call you because we need to make sure we can complete your appointment within 7 days of unprotected sex. CALL US NOW at : 604-709-5611.
For all other IUD/Implant appointments, once we have received this form we will call you
as soon as possible ( Mon – Fri ) to schedule the appointment.
Due to our large number of requests, it may be quicker
for you to call us directly. Thank you.