Implant Request

The only contraceptive implant (Nexplanon) is a small, flexible, plastic rod which is inserted under the skin of your upper arm. It lasts for 3 years but you can have it removed sooner if you wish.

The implant slowly releases a low dose of a hormone called progestogen. It is one of the most effective methods of contraception currently available, and you are very unlikely to get pregnant when using the implant.

Irregular bleeding is common when using the implant. Some people might bleed frequently, and other people might not bleed at all. The bleeding pattern can change at any time.

Please look at the following site is you require further information: Contraceptive implant

Please complete the implant request form below

Please confirm you are registered with an NHS Lothian GP Practice.

CHI Number

This is a 10 number reference that is personal to you, the first 6 numbers of this are your date of birth, this can be obtained from your prescription, your NHS card or you GP practice can give you this.

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Your home address and postcode.

This is to confirm you are resident within the NHS Lothian Health board.

Email *

Enter Email

Best number to call you on *

Name and address of your GP Practice (including Postcode)

This is used to notify them of your procedure and update your medical records. Please provide name of GP and town/area of your practice. Please be aware that failure to provide correct GP practice details is NHS fraud.

Please ensure you answer all questions.

What do you need ? *

Insert Implant for first time

Removal and exchange for new implant

Removal of Implant

Do you have any medical problems? *

Yes – please let us know below

Please provide information here

Do you think you could be pregnant? *

Yes

Have you had any irregular bleeding? *

Yes

Have you ever had any reactions to a local anaesthetic?

If not, please answer none.

Please add a comment or questions you have about the implant contraception.

I will eat breakfast on the day of the procedure.

I have read an fully understand the side effects, effectiveness and complications of the implant.

I am aware I need to use adequate contraception until device fitted and for up to a week afterwards.

I should seek review if at any time I cannot feel the implant.

I am aware the implant does not provide protection against sexually transmitted infections (STIs). Only a barrier method of contraception (such as a condom) can reduce the risk of STIs

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

How did you hear about us?

I consent to the practice collecting and storing my data from this form.

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