Contraceptive Implant (Nexplanon) Questionnaire

If you wish to request an implant removal and/or insertion, please submit this form.

Contraceptive Implant (Nexplanon) Questionnaire

Section

Do you consent to receiving texts and phone calls to this number?
Are you registered with The Oaks Medical Centre? *
Do you give us permission to contact your surgery for further information? *
Which procedure are you requesting: *

Implant Removal and Reinsertion

Please use this date format: DD/MM/YYYY
Has your implant expired? *
Have you been using additional contraception? *
Have you been using this reliably for the past 3 weeks? *
Have you had any unprotected intercourse in the past 3 weeks? *

Implant Insertion Only

Are you using any contraception? *
Have you been using this reliably for the past 3 weeks? *
Have you had any unprotected intercourse in the past 3 weeks? *

Implant Removal Only

Please use this date format: DD/MM/YYYY
Has your implant expired? *
Have you been using additional contraception? *
Have you been using this reliably for the past 3 weeks? *
Have you had any unprotected intercourse in the past 3 weeks? *
Do you require contraception after removal? *

If you are undecided or need a prescription for contraception, please make an appointment with an ANP before your implant is removed.

Do you have any unexplained vaginal bleeding? *
Do you have, or have you had, any of the following?
Breast cancer: *
Any cancer that you have been told is sensitive to the hormone progestogen: *
Blood clots in the legs, lungs or eyes: *
Stroke: *
Heart attack: *
Liver tumour or liver disease including cholestasis: *
Do you take any of the following medications?
Do you have any allergies? *

Please visit the following website and read the information on contracepive imlants:

I have read the information provided on contraceptive implants. *
I understand that no method of contraception is 100% effective and that there is a small risk of failure with the contraceptive implant (less than 1 in 100 over a year). *
I understand that the implant contains a hormone (progestogen) which may have side effects including breast tenderness, bloating, weight gain and mood changes. *
I understand that the hormone in the implant may make my periods irregular or infrequent or they may stop. *
I understand that there will be a small scar on the inside of the upper part of my arm. *
I understand there may be bruising, bleeding and infection at the site of the insertion. *
I understand that, rarely, there may be damage to nerves and blood vessels and there may be some post procedure discomfort, tingling and numbness. *
I understand that sometimes it may be difficult to remove the implant. Rarely, this may involve being referred to another clinic for removal. *
I understand that the implant should not be inserted if I am pregnant or think that I may be pregnant. *
I understand the implant should not be inserted if I have any unexplained vaginal bleeding. *
I have been using my current form of contraception reliably or not had any episodes of unprotected sex for at least 3 weeks. *
I understand I should continue using additional contraception for 7 days after the implant has been inserted. *
Please specify the following: *

Please:

  • Bring a urine sample if you are having an implant inserted.
  • Attend the appointment on time. If you are late your procedure will be cancelled.
  • If you are unable to make it to your appointment, please cancel (0121 389 2222) and it will be rescheduled.