Sexual health - contraceptive implant fitting form | Kent Community Health NHS Foundation Trust

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Sexual Health - contraceptive implant form

If you would like to have a contraceptive implant fitted, exchanged or removed please fill in this online form.

Please do not bring young children to the clinic during appointment/procedure unless discussed with the clinic in the first instance.
Type of referral
What type of referral are you making?
- Exchange
- New insertion
- Removal
Patient details
Date of birth(Required)
You need to be over 16 to use this service.
Postcode check(Required)
Please enter your postcode so we can check if you are eligible for this service. If not, please contact your local service.
Address(Required)
Address line 1 Address line 2 Town Postcode
Name(Required)
First name Surname
Phone(Required)
Email(Required)
Ethnicity(Required)
Other
Country of birth(Required)
Gender(Required)
Is your gender the same since birth?(Required)
Sexual orientation
Other
What contraception are you currently using?(Required)
- Combined Hormonal Contraception (Pills/Patch/Ring)
- Progestogen only contraception (Injection/Implant/Pill/IUDC
- Non-hormonal Contraption (Condoms/Copper Coil / Diaphragm or cap)
- None – Withdrawal/ Natural family planning -ovulation tracker
Do you need an interpreter at the face-to-face appointment?(Required)
- Yes
- No
What language do you need?(Required)
Exchange
I have had this implant in place for(Required)
Where was your device fitted?(Required)
Removal only
Removal of contraceptive implant needs to be done during a face to face consultation with a health care professional.

It is important, in order to avoid risk of pregnancy after removal of your device that you abstain from unprotected sexual intercourse in the 7 days before your appointment.

If you require removal and another form of contraception please call the Central Access Team on 0300 790 0245.
I have had this Implant in place for(Required)
Please call the Central Access Team on 0300 790 0245 .
Where was your device fitted?(Required)
Other
There are several reasons why you may want your Implant removed:(Required)
Please tell us more
Medical questions
Hidden
OLD INACTIVE Have you ever had any of the following conditions?
- Breast Cancer /cancer of any type
- Epilepsy
- Heart disease or irregular heart rhythm
- Any liver disease
- None of the above
- Other (please specify below)
Have you ever had any of the following conditions?(Required)
- Breast Cancer /cancer of any type
- Epilepsy
- Heart disease or irregular heart rhythm
- Any liver disease
- None of the above
- Other (please specify below)
Other, please specify(Required)
If you have any medical health problems please tell us more about your condition(Required)
Are you taking any medication that you have been prescribed or bought over the counter?(Required)
- Yes
- No
Please tell us what you are currently taking(Required)
Do you think you might be pregnant?(Required)
- Yes
- No
We would like to speak to you please call 0300 790 0245 or 0300 123 1678.
Have you had any unexpected vaginal bleeding recently? Such as bleeding after sex or bleeding between periods.(Required)
- Yes
- No
Please add details(Required)
Do you have any drug or other allergies? (including peanut, soya allergies or are lactose intolerant)(Required)
- Yes
- No
Please add details(Required)
How often do you have periods and when was your last one?
When was the last time you had any sexual contact with anyone?
Was the sex...
- Protected (condom used)
- Unprotected (condom not used)
Are any of the following applicable to you? In the last three months...
- Have you had a sexual partner from another country/region other than Western Europe, North America or Australia
- Do you have any tattoos or piercing that have been done unprofessionally (stick and poke / bamboo tattoo / prison tattoo)?
- Have you been paid for sex?
- Have you paid for sex?
- Have you received any medical treatment in another country (operation/blood transfusion/injection)?
- Have you had a blood transfusion?
- None of the above
If yes to any of the above please detail...
Have you had any new sexual partners in the last 3 months?(Required)
- 0
- 1
- 2 to 4
- 5+
If you think that you have been at risk of a sexually transmitted infection (STI), or if you have recently changed sexual partners you can order a test via www.sh.uk. We recommend a HIV test if you have never had one.

If you think that you may have symptoms of an STI or would like some advice about anything else please call the Central Access Team on 0300 790 0245 or 0300 123 1678.
Do you smoke or vape?(Required)
NHS stop smoking services help you quit - NHS (www.nhs.uk)
How often do you have a drink containing alcohol?(Required)
If you feel that your drinking is becoming an issue and you would like to access some help please visit Drink less - Better Health - NHS (www.nhs.uk)
Are you currently or have you ever experienced any of the below?
- Sexual assault
- Domestic abuse
- Mental health issues
- I do not want to answer
- This is not applicable to me
Would you like one of our clinicians to call you to discuss and offer additional support/advice?(Required)
- Yes
- No (I am safe and have received or am receiving support with this from other services and do not require contact at present)
How would you like us to contact you?(Required)
- Email
- Text
- Phone
Consent for implant exchange or new insertion
It is important that you click on the below links in order to get all the required information about the contraceptive method you have chosen and the fitting procedure you are consenting to . If after watching the video and reading all the relevant information you are unsure if this is the best contraception method for you, please do not submit this form and call 0300 790 0245 kent or 0300 123 1678 Medway.
- o Long-acting reversible contraception (LARC) - Contraception - Sexwise
- Contraceptive implant video
I confirm that I have watched the video on the contraceptive implant, or read the leaflets, or already have an implant and am familiar with the method.(Required)
Yes
I understand that no method is 100% effective and that the implant has a very small risk of failure (less than 1 in 100 chance of pregnancy).(Required)
Yes
I have been using contraceptive methods and will continue to do so until the day of fitting and for 7 days after implant insertion, so that there isn’t a risk of pregnancy (This includes consistent condom use, meaning no penis in contact with the vaginal area at all)(Required)
Yes
I am aware of the hormonal effects of the contraceptive implant and that irregular bleeding or no bleeding is common. I am also aware that headaches / nausea / mood swings and acne are less common side effects.(Required)
Yes
I am aware that the insertion/removal process will require the use of local anaesthetic and that there may be some bruising/ tenderness and slight swelling after the procedure.(Required)
Yes
I am aware that there is a small risk of infection at the removal site (less than 0.5%).(Required)
Yes
I am aware that removal of the implant will require a local anaesthetic injection and a small cut through the skin.(Required)
Yes
I am aware that as soon as the implant is removed there is a risk of pregnancy.(Required)
Yes
I am aware that I may need to use additional contraception after removal.(Required)
Yes
I understand that it is up to the clinician on the day as to whether it is safe or appropriate to fit the Implant (for example, not for contraceptive purposes or risk of pregnancy), therefore please review your answers for accuracy as if any information is inaccurate your procedure will not go ahead.(Required)
Yes
Consent for implant removal
Please watch the information about subdermal implants video.
- Contraceptive implant video
I am aware that the removal process will require the use of local anaesthetic and that there may be some bruising/ tenderness and slight swelling after the procedure.(Required)
Yes
I am aware that there is a small risk of infection at the removal site (less than 0.5%).(Required)
Yes
I am aware that removal of the implant will require a local anaesthetic injection and a small cut through the skin.(Required)
Yes
I am aware that as soon as the implant is removed there is a risk of pregnancy(Required)
Yes
I am aware that I may need to use additional contraception after removal(Required)
Yes
Thank you
Thank you for providing us with your health information.

This will be reviewed by one of our team members to check you are eligible for the procedure.
Date completed(Required)
DD slash MM slash YYYY

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Sexual health – contraceptive implant fitting form

Your information

Sexual Health - contraceptive implant form

Type of referral

Patient details

Exchange

Removal only

Please call the Central Access Team on 0300 790 0245 .

Medical questions

We would like to speak to you please call 0300 790 0245 or 0300 123 1678.

Consent for implant exchange or new insertion

Consent for implant removal

Thank you