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 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 full responsibility for my decision in this consent.


Patient Name and Signature:

Doctor Name :
Signature


Witness:
Signature and Stamp:
Date