Reception: Clarendon Lodge Implant Form

Implant insertion/replacement/removal form

THIS FORM IS FOR CLARENDON LODGE PATIENTS ONLY. IF YOU ARE A PATIENT AT ANOTHER PRACTICE & WOULD LIKE TO REQUEST A FITTING PLEASE CONTACT YOUR OWN PRACTICE INITIALLY.

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 choices  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.

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

 

Personal details
Appointment details

Further information

Is it important we avoid fitting an implant if you could be pregnant.

Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or leave this question blank

Implants do not protect against sexually transmitted infections.

If you have no current symptoms of a sexually transmitted infection but are concerned you may be at risk you can request an STI screen to be delivered to you at home via this link: https://www.freetest.me/

If you do have symptoms then please contact the sexual health clinic. Details can be found on this link: https://www.sexualhealthwarwickshire.nhs.uk/clinics.php

Some medical problems mean that certain methods of contraception are not suitable. Please fill in the following information:

And a few final bits of information
If the answer is no then you must complete this first prior to submitting the form

Thank you very much for completing this form. We will contact you as soon as possible.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

Information submitted through all secure forms, with the exception of the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form, is secured with a private key and is accessed over a secure connection by nominated staff. Information submitted through the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form is sent to The Leamington Primary Care Network via secure email.

We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 365 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.