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Implant fit questionnaire

Implant fit questionnaire

Section

What are you requesting an appointment for?
Do you suffer from any long term conditions?
Are you taking any medication?
Do you have any allergies?
Are you using contraception currently?
Are you having periods?

You must ensure that there is no risk you may be pregnant before the implant is fitted. Please make sure that you are correctly using a reliable form of contraception OR please ensure you do not have unprotected sex 3 weeks before the fitting.

Please wear a top with loose or short sleeves.

Please do not bring any children or babies to the appointment.

Confirmation

I understand that this is the most effective female method of contraception available but that no method is 100% effective and that there is a small risk of failure.

I understand that the implant will need to be replaced 3 years after insertion. It can be removed earlier.

Some hormonal effects due to the small amount of hormone in the implant have been recorded including greasy skin and tender breasts. There has been no evidence that it causes mood changes, headaches or weight changes.

A small amount of local anaesthetic will be injected to numb the skin before the implant is removed or inserted into the arm.

A tiny scar may form at the site of removal/insertion.

There is a risk of bruising, which is temporary, and a small possibility of infection or nerve irritation at the site of insertion.

A pressure bandage will be applied to reduce bruising after insertion of the device which can be removed after 24 hours.

I understand that it I important that I am not pregnant at the time the implant is fitted.

I understand that the implant will not protect me against sexually transmitted infections.

I understand that the implant takes 7 days to work, so I will need to abstain or use an additional form of contraception for a week after the implant is fitted.

Confirmation