Nexplanon Consent Form

Please complete this Nexplanon consent form as part of your care under the Kirkby Women’s Health Hub, providing LARC services to Kirkby:

*Only complete this form if you have been asked to by a clinician*

First Name

Surname

Date of Birth

Address

Street Address Address Line 2 City Postcode Country

What is the name of your GP practice? Select one of these options:

I understand the most common side effects and risks listed here: https://www.nexplanon.com/side-effects/ – Nexplanon is a 4 cm flexible implant which sits under the skin of the upper arm. It slowly releases the hormone progesterone which prevents pregnancy. It is more than 99% effective at preventing pregnancy. It lasts for 3 years after which it needs to be removed. You can have another implant if you choose. If you would like your implant removing early please contact the surgery. You will have an immediate return of fertility after it has been removed. Do not take St John’s Wart as this will make your implant less effective.

I understand it is possible to snap or move the implant. I understand I must avoid repeatedly touching it

I understand though Nexplanon is very effective contraception, if I think I am pregnant I will contact the surgery as soon as possible

I understand that Nexplanon will not protect me against sexually transmitted infections

I understand the information given and consent to Nexplanon insertion/removal by the clinician at the Kirkby Women's Health Hub