Implanon Procedure Consent

HFGP Consent Form for Implanon Procedure

Patient Details

First name *

Surname *

Date of Birth *

The insertion of IMPLANON NXT® involves a small plastic implant containing the hormone progestogen being inserted underneath the skin of the upper inner arm to act as a contraceptive against pregnancy for up to three years.

It is a highly effective form of contraception and is an alternative to the pill, IUD’s, Depo injections and sterilisation.
It is placed under the skin in the non-dominant arm. It is easily palpable once placed so that it can be easily removed. It may need US guidance if removal proves difficult. Removal and insertion may leave temporary bruising and a small scar
The slow progesterone release acts to inhibit ovulation and hence is a contraceptive. It is effective immediately if inserted in the first few days of menstrual cycle.
It must be removed after 3 years and it is your responsibility to ensure that it is removed after that time, as it will no longer be effective and pregnancy may follow. A record of date of insertion will be kept on file at the surgery.
The best time to have Implanon inserted is in the first few days of your period. If not inserted at this time, you will need to do a pregnancy test at time of insertion and again 4 weeks later.
Implanon is safe to use as postnatal contraception in breastfeeding women.
There is a tiny increased risk of breast cancer with all progesterone only contraception. Please inform your doctor if you have a family history of breast cancer and you think you are at high risk. The risk returns to normal risk after stopping the contraception.

All procedures have risks and side effects. It is important that you understand the specific side effects of any treatment.

Please read and cross the below statements to indicate that you have been told of these side effects and understand their implications.

Side effects may include:

Irregular bleeding, altered menstrual patterns, no periods, headaches, weight gain and breast symptoms
Bruising and discomfort for up to one week after insertion
The possibility of allergic reactions• the implant moving from its original position, which could make removal more difficult
Acne
weight gain
Mood swings
Uncommonly - severe anxiety and mood disorders

I confirm I have read the above. My treating Doctor has discussed with me the benefits, risks and side effects of using IMPLANON NXT® *

By signing this form, you confirm that:

I am aware of the effectiveness of IMPLANON NXT® as well as its relative effectiveness compared with other birth control methods. I am aware no birth control method is completely reliable so I could have a small chance of becoming pregnant

*

I understand that the IMPLANON NXT® implant must be removed by three years since leaving it in place for longer may increase the chances of a pregnancy. I am aware it is my responsibility to arrange removal *

The insertion and removal of the Implant may leave a small scar on the skin. I am aware that some people are predisposed to develop a thickened scar. A larger scar is likely if the IMPLANON NXT® implant is difficult to remove. Removal may require referral to a specialist in some circumstances. *

I understand that to reduce discomfort, my doctor will use a local anaesthetic when inserting and removing the IMPLANON NXT® implant *

I have advised my doctor of any known allergies, especially allergies to a local anaesthetic, sex hormones, plastics, metals, latex or any of the active or inactive ingredients or excipients contained in IMPLANON NXT® *

I have discussed with my doctor and understand the fees involved, which includes the cost, rebate and out of pocket expense, of the procedure. Fees differ for insertion only, removal only and removal with re-insertion.
*

I understand that I must advise my doctor of any medication I am taking, as well as advise any other doctors I see, that I have an IMPLANON NXT® implant, as these can reduce the effectiveness of IMPLANON NXT® *

Based on the information above, I willingly consent for my doctor to insert an IMPLANON NXT® implant for use as a contraceptive in my arm. By ticking off each of the items above, I acknowledge that these are understood by me and have been discussed with my doctor. *

Signature *

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Date *