SELF- REFERRAL FORM

Central Liverpool Primary Care Network (CLPCN)
Long-Acting Reversible Contraceptive (LARC) Service

Please note that this service is only available to patients registered at Liverpool GP Practices

Date of Referral: 	
Referring to: CLPCN LARC service	
	
Patient Details	
Surname:		Forename:		
		Date of Birth:		Title:		
		Gender:		Age:		
Address:	
	Contact phone no:

GP Practice: 		GP Practice Address:		
Any Disability:		
Interpreter Required (Y/N):		
Language of interpreter required:		
Main Spoken Language:		
Read Language:		
Ethnic Group:	.	
Are you using any form of contraception? If so please specify
		
Appointment Required		

 Contraceptive Implant insertion
 Contraceptive Implant removal
 Copper coil insertion
 Copper coil removal
 Hormonal coil insertion
 Hormonal coil removal

Please email the referral form to CLPCN-larc.service@livgp.nhs.uk 

A member of our admin team will contact you to arrange telephone triage with our sexual health clinician prior to arranging an appointment.