Make an IUD insertion appointment

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I wish to make an appointment for an IUD insertionĀ at the Medical Arts Centre.

By using this form, you will be sending information about yourself across the Internet. While every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to make your IUD appointment.

Name:

Type of IUD I wish to have inserted:

*Insertion of a 10 year copper IUD is usually reserved for women who have previously been pregnant

Did a health care provider recommend you to this clinic?

Care Card Number:

Date of Birth:

*if manually entering date, please use the format yyyy-mm-dd

Home/Main Phone Number:

Address:

City:

Email Address:
Consent to contact by email for appts: Yes

Cell Phone:
Consent to contact by text message for appts: Yes

Additional notes/questions for the inserting doctor: