IUD Booking Form – Willow Clinic

IUD/Implant Booking Form

Please enable JavaScript in your browser to complete this form.
Have you had an IUD before?
Choose the best answer
Is this an IUD for EMERGENCY CONTRACEPTION?
For your periods what do you use?
How heavy is your usual period?
Selected Value: 0
10 is the worst
Selected Value: 0
10 is the worst
Have you ever been pregnant?
Births - choose a #
Abortions
Miscarriages
Tubal / ectopic
Have you ever had an infection in your uterus or fallopian tubes, or a sexually transmitted infection, (e.g. gonorrhea, chlamydia, PID)?
# of sexual partners
month / year - PAP
Do you have any medical illnesses (diabetes, heart disease, etc)?
Are you taking any medication?
Are you allergic to any medication?

We apologize for the inconvenience, but we are currently not accepting any new online form submissions. Please call our office for an appointment. Thank you for your understanding.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

About Us

Willow Reproductive Health Centre is committed to delivering compassionate, inclusive, and high-quality reproductive health care, ensuring every patient feels respected, safe, and supported. 

 

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