Leamington Primary Care Network Implant Form

Implant insertion/replacement/removal form

The Leamington primary care network is made up of the 8 practices based in the area. We work together to improve the care of all patients in Leamington. To this end the network has established a service to provide long acting contraception closer to home. Patients from Cubbington Road, Sherbourne, Croft, Waterside, Whitnash, Spa & Warwick Gates are all eligible.

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 thee NHS 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.

Following this is you have any queries please email swg-tr.leamingtonpcnlarcservices@nhs.net

If you do have to cancel your appointment with less than a weeks notice please email the above address but also contact the practice where your appointment is booked. This is to ensure the appointment can be used by someone else. All other queries should only be directed to this email address.

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. This service is only for patients registered at GP practices within the Leamington Primary Care Network. Forms must be completed in the UK due to GDPR regulations.

Personal details

Full name

Date of Birth

Contact number (preferably mobile)

Registered GP practice

Appointment details

What type of appointment would you like?

If needed, please use this space to tell us a bit more about the type of appointment you would like

If you currently have an implant, what date is the replacement due?Please write N/A if not applicable

If your implant is overdue its replacement (and this should be done every 3 years), it is important you are using alternative contraception or have abstained from sex for at least 3 weeks prior to your appointment. Otherwise we may be unable to proceed with the replacement.

If you do not currently have an implant, or your current implant is out of date, please provide details of your current method of contraception herePlease write N/A if not applicable

Further information

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

Are you concerned you might be pregnant?

Do you know the date of your last period?Not everyone has a regular cycle. If you do not know the exact date please select the closest possible or write N/A

Implant removals (without replacement)

If you would like your implant removed and do not wish to have another inserted please ensure you are using condoms/alternative contraception or abstain from sex for 7 days prior to your appointment. This is because sperm can survive for up to 7 days, and so if your implant is removed in this time period there is a risk of pregnancy.

And a few final bits of information

Do you have any allergies?

What is your smoking status?

I confirm that I have read through the above linked consent form which contains information to ensure an implant can be fit/removed safely

I confirm that I have consulted with my GP who has recommended the implant as a suitable contraceptive option for meIf the answer is no then you must contact your GP practice for an appointment before submitting this 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.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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