Patietn Implanon Removal Consent Form ForForm



Patietn Columbus County Health Department

Nexplanon Removal Consent Form ForForm

1. When do Nexplanon capsules have to be removed?

Nexplanon capsule (implant) must be removed at the end of 3 years. Nexplanon will not keep you from getting pregnant after 3 years. They can be removed before 3 years. If you want to have them removed before 3 years, talk to your nurse or doctor.

2. What happens when Nexplanon is removed?

Numbing medicine is given before removing the capsule. A very small ¼ inch cut is made in the skin. There is usually very little pain. Sometimes the capsule comes out very easily. Sometimes tight tissue builds up around the capsule. This makes it take longer to remove the capsule. You may feel your skin being rubbed and tugged. You may feel pressure. A bandage will be put on your arm. Keep this dry and clean. Remove the bandage the next day or as ordered by doctor or nurse. Your arm will be sore and may have some swelling for a few days. Your arm may look bruised for several days.

• It usually takes 10-15 minutes to take out Nexplanon capsules. Sometimes you may have to come back a few weeks later to get the capsules out.

• Call your doctor or clinic if your arm swells or hurts after the third day, or if you see pus or have a fever.

• Once the Nexplanon capsule is taken out, you could get pregnant right away. If you do not want to get pregnant, use another birth control method. Always use condoms and foam each time you have sex, if you need to protect yourself against AIDS and sexually transmitted diseases.

• Give reason for Nexplanon removal (used for studies only):

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Patient information label

I give my consent for the Nexplanon capsule to be removed.

________________________ ___________ ___________________

Patient Signature Date Witness

If under 18 years of age

I was counseled about the importance of discussing birth control needs and the removal of Nexplanon with my parent(s) or family members.

________________________ ___________ ____________________

Patient Signature Date Witness

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