CONTRACEPTIVE REMOVAL CONSENT FORM


Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Procedure Time:
Doctor Name:

I have been informed and understand that I may become pregnant right after the device is taken out. If I do not want to get pregnant after the contraceptive implant is removed, I may have a new one put in today or choose a different method of birth control to start today.

I understand it could take up to 30 minutes to take the implant out.

I understand that a small skin cut will be made close to the tip of the implant so that it can be removed. I am aware that I might feel some discomfort or pain during this procedure

I am aware of possible problems that might occur when taking the implant out, such as

  • An allergic reaction to the anesthetic or cleaning solution
  • Bruising or soreness where the implant was removed
  • Infection
  • Breakage of the implant
  • The need to make a second cut in order to take the implant out
  • The need for a second visit to take the implant out

I have read and understand this form and would like to proceed with having my contraceptive implant removed today

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take full responsibility for my decision in this consent.


Patient Name and Signature:

Doctor Name :
Signature


Witness:
Signature and Stamp:
Date