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

Your information

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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

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

Please tell us what you are currently taking(Required)

Do you think you might be pregnant?(Required)

Yes

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

Please add details(Required)

Do you have any drug or other allergies? (including peanut, soya allergies or are lactose intolerant)(Required)

Yes

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)

2 to 4

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)

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.

Consent for implant removal

Please watch the information about subdermal implants video.

Contraceptive implant video

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)

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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