Contraceptive Implant Questionnaire

By completing this form you are requesting to go on our list for a contraceptive implant fitted/changed/removed; please read and complete the following questionnaire to be placed on our waiting list (up to 6 weeks).

An appointment for Implant fitting/change/removal is 30 minutes with both a nurse and a doctor which is the equivalent to 6 normal appointments, so patients who do not attend their appointments without warning are preventing another lady from receiving contraception or 6 patients who are unwell being cared for.

There are very few people for whom sub cutaneous implant contraception is not suitable, but prior to fitting some do need further investigations. To try to save you time by avoiding unnecessary appointments we are using this questionnaire.

Contraceptive Implant Questionnaire


Do you have, or have you had breast cancer? *
Do you have, or have you had a blood clot in your legs or lungs? *
Do you have serious liver disease or jaundice? *
Are you taking any of the following medication (these medicines can affect the implant)?
Do you have any bleeding between periods which is unusual for you or any bleeding after sex? *
Are you sexually active now? *
Please use date format: DD/MM/YYYY
For more information, please visit NHS: Contraceptive Implant.
Do you consent to us contacting you via your mobile phone number about the implant and other clinical matters? *

Please be aware there must be no risk of pregnancy when you attend for your implant fitting i.e. you must be using a reliable method of contraception since your last normal period (withdrawal method is not a reliable method) or not have had sex since your last period.

The procedure involves an injection or small cut under local anaesthetic. There is usually a tiny white mark left on the skin. There is a small risk of bruising, bleeding or infection.

If you would like to discuss your request further, please request a routine telephone consultation with Dr Hannah Davidson.