Removal of Implant Contraception Self-Assessment

Removal of Implant Contraception Self-Assessment

Patient Details

Required field(s) are indicated by *

Please use the format DD/MM/YYYY

It is important that you are suitably informed prior to the removal of your contraceptive implant. Please confirm the following:

I understand that there is a risk of infection: *
I understand that there will be a scar on the inside of the upper arm: *
I understand that in rare circumstances it may take more than one attempt to remove the device and you may need to have this done in hospital: *

I would like to have the implant removed because of:
Would you want the implant replacing? *
Are you aware of an immediate return to fertility? If you are not having the implant reinserted, you would need to consider alternative contraception for 5 days prior to removal. *
Would you like pre-conception information?

Please visit NHS: Planning your pregnancy for more information.

Smoking status:
Would you like help to quit smoking?
*