Informed Consent For Contraceptive Implant (Nexplanon) Removal

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) removed.

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

Consent For Contraceptive Implant (Nexplanon) Removal

Patient Details

Consent

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

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