Westbourne Medical Centre consent form

Name of Patient...................................................................................

Date of Birth.................

Address...............................................................................................

Patient agreement to treatment

Insertion of contraceptive implant (implanon)

The intended benefits:

Serious or frequently occurring risks:

Very rarely, soon after the implant is put in it can cause an infection in your arm, where it has been inserted.
Research about the risk of breast cancer and hormonal contraception is complex and contradictory. Current research suggests that women who use hormonal contraception appear to have a small increase in risk of being diagnosed with breast cancer compared to women who don’t use hormonal contraception. Further research is ongoing.

I have confirmed that the patient has read “Your guide to the contraceptive implant” and have given her the opportunity to ask any questions.

Signed: .........…………………………………… Date ..........................

Name (PRINT) ………………………..………. Job title ………………………………………….

I have read “Your guide to the contraceptive implant”
I agree to the procedure described above.
I understand that the person performing the procedure will have appropriate experience.
I understand that the procedure will involve anaesthesia.
I confirm - that I have been using alternative contraception or avoided intercourse since my last normal period

Signature ………………………………………. Date ............................

Name (Print) ........................................................

This form will be scanned into your medical records. If you would like a copy, please ask at reception.