Informed Consent for Contraceptive Implant

Consent

Please tick the boxes to confirm that you have understood and consent to having a contraceptive implant (Nexplanon) removed:

Please confirm the following: *

I understand the details of the procedure, including the anticipated benefits and material risks, that have been explained to me.

I am not allergic to iodine or anaesthetics.

I have asked to have the contraceptive implant (Nexplanon) taken out of my arm.

I am aware that when the implant is taken out, its contraceptive effects will not continue, so if I don’t want to get pregnant after Nexplanon is taken out, I can have a new implant put in or choose a different method of birth control today.

I understand that it takes up to 30 minutes to take out Nexplanon, or longer if there are difficulties. First, the skin over the implant will be cleaned and numbed. Next, a small cut will be made close to the tip of the implant so that it can be removed. I am aware that I might feel some discomfort during this procedure. Once the rod is removed, I may experience light bleeding, bruising or soreness at the incision site for several days.

I understand and accept that there might be complications with any procedure and I am aware of the possible problems that might occur when taking out Nexplanon explained below.

An allergic reaction to the anaesthetic
Pain and/or irritation at the removal site
Swelling or bruising where the implant was removed
Infection
The implant could break and a second cut could be needed to take out the implant
A second visit could be needed to take out the implant
Need for a special procedure such as outpatient or hospital surgery to remove the implant
Difficult removals may cause pain or scarring

I understand that if the Nexplanon implant cannot be found, its effects may continue.

I have informed the doctor of all my known allergies.

I have informed the doctor of all the medications I am currently taking including prescriptions, over the counter remedies, herbal therapies, aspirin and any other recreational drug or alcohol use.

I have had an opportunity to ask questions and discuss my concerns.

The doctor has answered all my questions regarding this procedure.

If I experience bleeding, redness or pus from the incision site I will seek medical attention.

Please select which option you would like to opt for: *

I choose to start using birth control

I do not choose to start using birth control

Please specify which birth control:

I certify that I have read and understand this treatment agreement.

Signature: *

Date:

Section

Consent

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Informed Consent for Contraceptive Implant

Section

Consent

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