Assessment for contraceptive implant insertion - Maidstone and Tunbridge Wells NHS Trust

Contraceptive implant insertion

The ENG-IMP (Contraceptive Implant/Nexplanon) provides very effective contraception for 3 years. It is estimated to be 99.95% effective in its first year and the contraceptive effect is lost rapidly after removal. It may also provide help with heavy or painful periods. So we offer the best and safest service and to ensure our appointments are used optimally, please fill in the questionnaire below. Once you have returned the form, one of our staff will be in touch within 14 days to book your Implant insertion appointment. Please contact us at mtw-tr.coilassessmentdoc@nhs.net if you don’t hear anything within 14 days of submitting your form.

Important

Do not use this form if you require a copper coil insertion for emergency contraception, i.e. you have had sex without using any contraception since your last period. In this situation, please contact the Rubin Clinic directly ASAP on 0300 3730709.

Please note

If there is any risk of pregnancy, it may not be possible to fit the implant. So, please either abstain from sex or use a reliable method of contraception correctly for at least 21 days prior to the procedure. Reliable methods of contraception do not include withdrawal or fertility awareness methods/apps.

Full name(Required)

Date of birth(Required)

Age(Required)

Phone number(Required)

Email address(Required)

Please ensure these contact details are correct. Also be advised that it is really important that you are not pregnant at the time of implant insertion.

Have you used the implant before?(Required)

If answered 'yes' how long ago was it removed?(Required)

Did you have any side effects with it?(Required)

If answered 'yes' please give details...(Required)

What was the first day of your last period?(Required)

Was this a normal period for you, at the expected time?(Required)

What is your current contraceptive method?(Required)

If answered 'other' please specify(Required)

Have you taken EMERGENCY CONTRACEPTION in the last three weeks?(Required)

If required, please continue using your contraception reliably until your Implant is fitted. For your safety, we must ask some sensitive questions to assess the risks of sexually transmitted infections:

How long have you been together with your current sexual partner?(Required)

Have you had a new sexual partner in the last 12 months?(Required)

Have you had more than one sexual partner in the last 12 months?(Required)

Does your sexual partner have other sexual partners?(Required)

Have you ever had any sexually transmitted infections?(Required)

Have you been in contact with anyone who has had a sexually transmitted infection (STI)?(Required)

Have you had any new vaginal discharge?(Required)

If the answers to any of the infection questions are YES, please visit the website SH.UK and register to receive an STI screening kit. You can then do the STI screen in the comfort of your own home and once complete please post as per the instructions. The results will be sent as a text to your mobile phone.

Are you experiencing abnormal vaginal bleeding? By that we mean bleeding between periods, bleeding after sex or new and un-investigated bleeding that is heavier or irregular?(Required)

Have you had a Termination of Pregnancy (abortion) in the last 3 weeks?(Required)

Are you up to date with your cervical screening?(Required)

Do you have any other medical conditions?(Required)

If yes, please give details...(Required)

Do you take any medication?(Required)

If yes, please give details...(Required)

Are you allergic to anything?(Required)

If yes, please give details...(Required)

Have you ever had a local anaesthetic for any other procedure?(Required)

If 'yes', were there any problems with the anaesthetic?(Required)

If 'yes' please give details...(Required)

Is there any other information you would like to tell us that you think might be important or helpful? e.g. did you faint or feel faint at your last coil fit; was a General Anaesthetic required; any specific pain relief requests; is it for HRT or non-contraceptive use…?(Required)

What would be your preferred clinic?(Required)

Although we cannot guarantee a time to call you back, which would be your preferred time slot?(Required)

We will try to call you on two occasions – the number will be displayed as withheld.

If we are unable to contact you by phone, we will send an SMS or leave a voice message inviting you to call in to make an appointment. If you do not want us to leave a voice message or send an SMS, please check the box.

Further information

Video on implant fitting

Patient information leaflet on the contraceptive implant

Patient information leaflet on the hormonal coil

Please be prepared to provide a urine specimen on the day, prior to your procedure.
Please ensure you have eaten and been drinking normally prior to the appointment.
It is advisable to wear a loose or short sleeved top.
Please do not bring any children to the appointment
You may bring someone to accompany you to wait in the waiting room during your appointment.

If there is any risk of pregnancy, it may not be possible to fit the implant. So, please either abstain from sex or use a reliable method of contraception correctly for at least 21 days prior to the procedure (reliable methods of contraception do not include withdrawal or fertility awareness methods/apps).