Contraception – Mirena Coil – New Referral Letter

○ Pregnancy (current or in the last 6 weeks)
○ Abnormal vaginal discharge
○ Bleeding in between periods
○ Current or recent infection of the genital tract or a history of Pelvic Inflammatory Disease
○ Current or past history of liver, breast, cervical or uterine (womb) cancer

○ I am 18 years old or over, and currently in Australia.
○ This referral is for my own personal use only.
○ I understand that I am responsible for advising my specialist, and any other healthcare professional(s) I attend, of relevant information relating to my health and any changes in my health.
○ I understand that there may be a waiting list to see a specialist- if my condition gets worse in the interim I will seek medical attention.
○ I am aware there may be out of pocket costs for attending a specialist, which I will discuss with them.
○ I agree to the terms and conditions of use.