Informed Consent For Contraceptive Implant (Nexplanon) Insertion

If you have been advised by the surgery to do so, please submit this form.

Please select the boxes to confirm that you have understood and consent to having a contraceptive implant (Nexplanon) fitted.

If you have any questions or are unsure if you meet the criteria, please contact the practice.

Consent for Contraceptive Implant (Nexplanon) Insertion

Patient Details

Please use this date format: DD/MM/YYYY.

Consent

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

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Benefits

  • Convenience - no pills to remember, lasts for 3 years
  • One of the most reliable methods of contraception (99% effective)
  • May lighten or stop periods
  • Normal level of fertility returns as soon as implant is removed

Risks/disadvantages

  • Erratic bleeding patterns are possible
  • Possible side effects - acne, breast tenderness, bloating, mood swings
  • Small risk of infection when implant is inserted or removed
  • Small scar on arm where implant is inserted and removed
  • Although the implant is very effective, there is a small failure rate (<1/1000 in 3 years)
  • I understand that this is a contraceptive device, but will not protect me against sexually transmitted infections
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