LARC data form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

LARC data form

Step 1 of 2

Please make sure any details entered are correct.

There is a 'Save and continue' option at the bottom, although please make sure you don't miss claims needed. This saves for 90 days, please ignore the message on screen where it says 30 days.
Practice summary
Your email(Required)
Practice name(Required)
Practice confirmation(Required)
- Please confirm you have selected the right practice, as mistakes cannot be rectified after invoices have been submitted
Quarter(Required)

Full GMS Patients

Description	Price	Quantity	Amount

Temporary GMS Registered Patients

Description	Price	Quantity	Amount

Date of procedure	Fitted by	Age of client	Chlamydia Screen Status	LARC procedure	Time from insertion to removal	Reason for removal

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LARC data form

Your information

LARC data form

Step 1 of 2

Practice summary

Patient details