Implant Form

If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners, you can order a test via www.friskywales.org.

We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like soem advice about anything else please call the CRI sexual health clinic on 029 2183 5208. 

On completion of this form the information you provide will be sent to our womens health practitioner for review. 

Last Updated: 16/05/2024

  • Personal Details

    Date of Birth
    For example, 15 3 1984

  • Further Information

    Have you ever had any of the following conditions?
    Are you taking any medication that you have been prescribed or bought over the counter?
    Do you have any drug or other allergies? (Including peanut, soya allergies or are lactose intolerant)
    Do you think you might be pregnant?
    Have you had any unexpected vaginal bleeding recently, such as bleeding after sex or bleeding between periods?
    What was the first day of your last period?
    For example, 15 3 1984
    Have you had more than one sexual partner in the last year?

  • Consent

    This form collects your name, date of birth, other personal information and medical details. This is to confirm you are registered with the practice, to allow Waterfront Medical Centre to contact you, and update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form. 
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