Contraceptive Implant Consent Form

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Please only complete this online consent form if you have been asked to by a clinician following a consultation. If you don't understand anything in this form, then please book another appointment with a GP to discuss it further.

Personal Details
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Pre-Consent Information
Method of Action
 
Effectiveness
 
Duration
Procedure

If you have not been advised that a prescription has been sent to your pharmacy of choice, please contact reception as soon as possible.

Do you have any allergies to local anaesthetics or dressings: *
Side Effects & Risks
Pregnancy Risk Statement

If you:

Are using Condoms or are having unprotected sex: abstain from sex from the start of your period prior to your Implant fitting appointment.

Have Irregular/absent periods: abstain from sex for 3 weeks prior to the fitting appointment and do a home pregnancy test the day before your fitting.

Are using Hormonal Contraception: continue on your current contraception until the procedure (and ensure no missed pills/patches etc).

Have Long acting contraception (IUD/IUS/Implant) that has expired: abstain from sex for 3 weeks prior to the fitting appointment and do a home pregnancy test the day before your fitting.

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Declaration

By Signing below I can confirm that I have having read and understood the above, I agree to the Insertion of the Implant

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Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Contact

Violet Lane Medical Practice
231 Violet Lane
Croydon
CR0 4HN

Telephone: 020 8688 0333

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Providing NHS Services

Care Quality Commission
Rating: Good