Implant & Nexplanon

Your Details

Full Name *

Address (Including Postcode) *

Date of Birth (DD/MM/YYYY) *

Contact Number *

Email Address *

Implant Questions

Do you have any known allergies? *

Yes No

Weight or BMI? *

Do you smoke? *

Smoker

Ex-Smoker

Non-Smoker

If you smoke how many do you smoke per day?

If you've quit smoking, when did you stop?

Are you currently using Contraception? *

Yes No

If Yes to currently using Contraception please give details of what you are using currently?

If you are aged 25 and over, are you up to date with your Cervical Screening? *

Yes No

Are you awaiting referral to Colposcopy following a smear test? *

Yes No

Do you have any of the following (please select)

Breast Cancer or a past history of Breast Cancer

Unexplained vaginal bleeding

Liver disease including cholestasis

Do you take any of the following?

Epilepsy Medication

HIV/AIDS Medication

St John's Wart Herbal Remedy

None of the above

If you have selected any of the above please give more details here

Do you have any of the following?

If you have selected any of the above conditions please provide further details

Have you researched the implant as a method of contraception? *

Yes No

If No, please visit the NHS Website for further information such as possible side effects - https://www.nhs.uk/conditions/contraception/contraceptive-implant/ *

Yes I will visit the NHS Website to find out more

No I will not visit the NHS Website to find out more

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Implant & Nexplanon

Implant & Nexplanon

Further Information