IUD Booking Form

If you are not sure which IUD you want, please read our IUD information page.

Please fill out this form if you wish to book an appointment for an IUD insertion. We will try to call you back within 3 – 5 business days to schedule the appointment. Even if you have filled out the form you can still try and call us directly. Our phone lines are very busy but you may get an appointment faster.

If this IUD is for Emergency Contraception, don’t wait for us to call you because we need to make sure we can get your appointment within 7 days of unprotected sex.

Instructions:

Your appointment will be approximately 45-60 minutes.

Please make sure you have had something to eat and take some ibuprofen 1 hr before your scheduled time.

Please bring a pad with you as you may have some bleeding




Questionnaire:
Name as on medical Card*:
Preferred first Name*:
Date of birth*:
/ /
Address*:
City*:
Postal Code*:
Phone (cell, home, work) Cell*:

Please contact me on this number
Home:

Please contact me on this number
Work:

Please contact me on this number
Email address*:

 
Emergency contact (Name & Number) *:

 
#*:
please contact me on this number
Care Card #
Referring Doctor Name
Phone Number
Do you already know which type of IUD you want ?
YesNo
Do you already have a prescription for the IUD?
YesNo

If you have extended health benefits (insurance) that will pay for your IUD,we need to have a pharmacy name and fax number so we can send the prescription.MacDonald's Pharmacy in our building has IUDs in stock.

If this IUD is for Emergency Contraception, don't wait for us to call you because we need to make sure we can get your appointment within 7 days of unprotected sex.

Once we have received this form we will call you within 2 business days (Mon-Fri) to schedule the appointment.


Suite 1013 – 750 West Broadway Vancouver BC V5Z 1H9
Ph. : 604-709-5611
Fax : 604-873-8304
Email: willowwomensclinic@yahoo.ca