Contraceptive implant fitting

Section

Confirmation *

I confirm that I have watched the video on the contraceptive implant, or read the leaflets, or already have an implant and am familiar with the method

Confirmation *

I have been using contraceptive methods and will continue to do so until the day of fitting so that there isn’t a risk of pregnancy

Confirmation *

I am aware of the hormonal effects of the contraceptive implant and that irregular bleeding or no bleeding is common. I am also aware that headaches / nausea / mood swings and acne are less common side effects

Confirmation *

I am aware that the fitting process will require the use of local anaesthetic and that there may be some bruising/ tenderness and slight swelling after the procedure

Confirmation *

I am aware that there is a small risk of infection at the insertion / removal site (less than 0.5%)

Confirmation *

I am aware that the risk of pregnancy is very low but to do a pregnancy test and inform the doctor if pregnant If the implant is still inserted

Confirmation *

I am aware that the implant when removed will require a further cut to remove the implant with local anaesthetic

Are you on any medications that may affect the implant – (Anti-Retrovirals / Anti-epileptic medication / Mood stabilisers)? *

Yes

No

Please specify: *

Do you have a history of liver disease / inflammatory bowel disease / inflammation of the gallbladder caused by contraception? *

Yes

No

Please specify:

Confirmation *

I am aware that I may need to use additional contraception after fitting dependent on my method of contraception currently

Confirmation *

I am aware that I will seek medical advice if worsening pain or fever in or around the site of insertion or if I cannot feel the implant in the future

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