Implanon Insertion Consent
1. I hereby authorise the doctor to perform upon me the following procedure: Implanon Insertion.
2.I have discussed the purpose, the benefits/risks and side effects of Implanon Insertion with the doctor. The nature of the procedure has been fully explained to me.
3. I understand that the risks of Implanon Insertion include, but are not limited to:
- The doctor being unable to do Implanon Insertion on the day
- fainting after or during the procedure (this may require prolonged observation or an injection)
- Anaphylactic Reaction
- Irregular Bleeding, no bleeding, headaches, weight gain and breast symptoms.
- Bruising and discomfort for up to one week after insertion
- the implant moving from its original position, which could make removal more difficult
- Scarring
4. I acknowledge that no guarantee or assurance has been made to me regarding the results that will be obtained from this procedure.
5. I authorise the staff of AIM Health Melbourne Student Medical Centre to administer all necessary first aid and/or resuscitation measures in the unlikely event that an adverse or anaphylactic reaction occurs.
6. I am aware of the effectiveness of Implanon as well as its relative effectiveness compared with other birth control methos. I am aware no birth control methos is completely reliable so I could have a small chance of becoming pregnant.
7. I understand that the Implanon must be removed by three years since leaving it in place for longer may increase the chances of an ectopic pregnancy and I should have an annual check up while the implant is inserted
8. I certify that I have read and fully understand the above consent to Implanon Insertion and the associated explanations given by the doctor. All my questions have been answered to my satisfaction.
Client’s name: _________________ Client’s signature:_______________
Date: ________________________
Inserting doctor’s name: _______________ Doctor signature: ______________
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