Implant insertion/replacement/removal form

Long-acting contraception can provide a safe and effective method of contraception. 

The contraceptive implant is a small rod sited in the upper arm which provides contraception for up to 3 years.

More information can be found on theNHS UK and sexwise websites. 

If you are considering using an implant, or would like to have a current implant replaced or removed please:

  • Read through this information
  • Watch the video below
  • Carefully read through the consent form
  • Complete a consultation with your GP & agreed that an implant would be a suitable option for you
  • And then submit the online form below. We will then contact you to arrange an appointment.

Please fill in as much information as possible to help us arrange your appointment efficiently.

Some of this information will already be included in your medical notes but this is a good opportunity to update any changes.

Video: Having a contraceptive implant fitted

Implant insertion/replacement/removal form

Step 1 of 2

Date of Birth  Required
Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or leave this question blank
Do you have, or have you ever been diagnosed with?  Required
Are you taking any of the medications below?  Required