Long Acting Contraceptive Service (LARC) Implant Self-Referral 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?

Implant exchange Optional

Implant new insertion Optional

Implant removal Optional

Patient details

Name

First Last

Date of birth

Day

Month

Year

Contact number

Address

Street Address Address Line 2 City Postcode

Email address

Ethnicity

Please specify

Country of birth

Gender

Is your gender the same since birth?

Sexual orientation

Other Optional

Do you need an interpreter at the face-to-face appointment?

Yes

What language do you need?

Exchange

I have had this implant in place for

Where was your device fitted?

New insertion

What contraception are you currently using?

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

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

Please call the Central Access Team on 0300 790 0245 .

Where was your device fitted?

Other

There are several reasons why you may want your Implant removed:

Please tell us more

Medical questions

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)

If you have any medical health problems please tell us more about your condition

Are you taking any medication that you have been prescribed or bought over the counter?

Yes

Please tell us what you are currently taking

Do you think you might be pregnant?

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.

Yes

Please add details

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

Yes

Please add details

How often do you have periods and when was your last one? Optional

When was the last time you had any sexual contact with anyone? Optional

Was the sex…

Protected (condom used) Optional

Unprotected (condom not used) Optional

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 Optional

Do you have any tattoos or piercing that have been done unprofessionally (stick and poke / bamboo tattoo / prison tattoo)? Optional

Have you been paid for sex? Optional

Have you paid for sex? Optional

Have you received any medical treatment in another country (operation/blood transfusion/injection)? Optional

Have you had a blood transfusion? Optional

None of the above Optional

Please give details Optional

Have you had any new sexual partners in the last 3 months?

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?

NHS stop smoking services help you quit – NHS (www.nhs.uk)

How often do you have a drink containing alcohol?

Never – I do not drink alcohol

Once a month or less

2 to 4 times a month

2 to 3 times a week

4 or more times a week

I do not want to answer

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 Optional

Domestic abuse Optional

Mental health issues Optional

I do not want to answer Optional

This is not applicable to me Optional

Would you like one of our clinicians to call you to discuss and offer additional support/advice?

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?

Text

Phone

Date completed

Month

Day

Year

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.

– 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.

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).

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)

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.

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.

Yes

I am aware that there is a small risk of infection at the removal site (less than 0.5%).

Yes

I am aware that removal of the implant will require a local anaesthetic injection and a small cut through the skin.

Yes

I am aware am that as soon as the implant is removed there is a risk of pregnancy.e that removal of the implant will require a local anaesthetic injection and a small cut through the skin.

Yes

I am aware that I may need to use additional contraception after removal.

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.

Yes

Consent for implant removal

Please watch the information about subdermal implants video.