XXXXXX Health Center
Address:
Phone:
____ I request an IMPLANON (progestin implant).
I understand the following:
____ I will have a pregnancy test before the Implanon is inserted. If I had unprotected sex within the past 14 days, the pregnancy test may be negative even if an early pregnancy has begun.
____ The Implanon protects against pregnancy for 3 years.
____ The possible risks of Implanon include skin infection, scarring of the skin, bruising and swelling in the arm where it was placed
____ I expect to have spotting and irregular bleeding. My periods may change. I may have more bleeding, less bleeding, or no bleeding during my periods.
____ The Implanon does not protect against STDs. I should use latex condoms to protect myself against STDs.
____ I may check for the Implanon by feeling for the rod under my skin. I will come into the office if I can’t feel the rod.
____ I have a sheet that explains what to expect after Implanon placement.
____ I consent that _____________________________ insert the Implanon for me.
Signature of patient:____________________________ Date:____________
Signature of provider:___________________________ Date:____________
Witness: _____________________________________ Date:____________
