Implant consent

Please complete this the implant request form below.

A contraceptive implant is a small, flexible rod that’s placed just under the skin of your upper arm.

It releases a progestogen hormone similar to the natural progesterone produced by the ovaries.

It works for 3 years.

Contraceptive implant – Contraception – Sexwise

Please use format day/month/year e.g. 12/05/1979
Enter Email
One of our clinicians will contact you on this number in the next few days.

Please ensure you answer all questions.

What do you need ? *
Do you have any medical problems? *
Do you think you could be pregnant? *
Have you had any irregular bleeding? *

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.