Removal of Implant Contraception Self-Assessment

Removal of Implant Contraception Self-Assessment

Section

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? *

If you would like the implant to be replaced, please also complete an Implant Self Assessment after you have submitted this form.

*
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?
*