CONTRACEPTIVE IMPLANT INSERTION CONSENT FORM

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

Contraceptive Implant Insertion



I consent to the insertion a contraceptive implant. I confirm that the following risks and benefits of the procedure have been explained to m.

Benefits:
• Convenience – no pills to remember, lasts for 3 years.
• One of the most reliable methods of contraception (99% effective).
• May lighten or stop periods.
• Normal level of fertility returns as soon as implant is removed.

Risks/Disadvantages:
• Erratic bleeding patterns are possible.
• Possible side effects – acne, breast tenderness, bloating, mood swings.
• Small risk of infection when implant is inserted or removed.
• Small scar on arm where implant is inserted and removed.
• Although the implant is very effective, there is a small failure rate (<1/1000 in 3y).

I understand that this is a contraceptive device, but will not protect me against sexually transmitted infections.

I understand that it is important that I am not pregnant at the time the implant is fitted.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

"I agree that healthcare provider(s) involved in my care at this facility will access my health information through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".
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 the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :