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Implant insertion self assessment

Implant Insertion Self-Assessment Checklist – Westgate
Required fields are labelled
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

Assessment

It is important that you are suitably informed prior to the fitting of your contraceptive implant. Please confirm the following:
I have read the information on contraceptive implant information provided Required
I understand that no method is 100% effective and that there is a small risk of failure (less than 1 in 100 over a year) Required
I understand the device contains hormones and may have related side effects including breast, pain, weight gain and changes in mood. Required
I understand that there is a risk of infection Required
I understand that there will be a scar on the inside of upper part of arm Required
I understand that the implant may be visible Required
I understand thatvery rarely there may be damage to underlying nerves and blood vessels during the procedure Required
I understand that in rare circumstances it may take more than one attempt to remove the device and you may need to have this done in hospital Required
I understand that the implant may make my periods irregular or they may stop Required
I understand that it is not safe to insert an implant if there is a risk of pregnancy Required
I am not at risk of pregnancy because: Required
Please use this date format: DD/MM/YYYY.
E.g. Monday AM/PM, Tuesday AM/PM
Confirmation Required