Contraceptive Implant Questionnaire

If you have been advised by the surgery to do so, please submit this form.

Contraceptive Implant Questionnaire

Contraceptive Implant Questionnaire

Section

Do you have, or have you had breast cancer? *
Do you have, or have you had a blood clot in your legs or lungs? *
Do you have serious liver disease or jaundice? *
Are you taking any of the following medication (these medicines can affect the implant)?
Do you have any bleeding between periods which is unusual for you or any bleeding after sex? *
Are you sexually active now? *
Please use date format: DD/MM/YYYY
For more information, please visit NHS: Contraceptive Implant.
Do you consent to us contacting you via your mobile phone number about the implant and other clinical matters? *

Please be aware there must be no risk of pregnancy when you attend for your implant fitting i.e. you must be using a reliable method of contraception since your last normal period (withdrawal method is not a reliable method) or not have had sex since your last period.

The procedure involves an injection or small cut under local anaesthetic. There is usually a tiny white mark left on the skin. There is a small risk of bruising, bleeding or infection.