Name ________________________________________ Chart No. _________________
BENEFITS: I am voluntarily choosing to use a Hormonal Implant as a method of family planning. The hormonal implant is effective for three years. It may be at least 99 percent effective in preventing pregnancy. Breastfeeding may continue when using a hormonal implant.
RISKS/SIDE EFFECTS: I am aware that while using a hormonal implant as a method of family planning, I may have the following side effects:
- Bleeding irregularities
- Depression
- Mood swings
- Pain or irritation near implant site
- Breast Pain
- Vaginitis
- Infection at implant site
- Acne
- Trouble using contact lenses
- Headache
- Weight gain
- Darkening of the skin, especially face
Cigarette smoking increases the risk of serious cardiovascular side effects. I understand that certain medications (mainly medications for seizures, St. John’s Wort, hepatitis C medications and anti-HIV protease inhibitors) may make the hormonal implant less effective.
I have been told that in order to lessen the chance of serious complications from my hormonal implant, it is my responsibility to visit the family planning clinic, a doctor or a hospital emergency room if I start having the following DANGER SIGNS:
- Sharp chest pain, crushing chest pain or heaviness in chest
- Difficulty sleeping, weakness, lack of energy, tiredness or sadness
- Pus or bleeding at the insertion site
- Heavy vaginal bleeding
- Implant breaking through the skin
- Shortness of breath or coughing blood
- Persistent pain in the calf of the leg
- Yellowing of the skin or whites of your eyes
- Sudden or severe headaches or vomiting, dizziness or fainting
- Breast lumps
- Problems with speech, vision, weakness or numbness in arms or legs
- Severe pain, swelling, or tenderness in the abdomen
ALTERNATIVES: You have received information about the other methods of birth control that are available. For situations of suspected contraception failure, emergency contraception is available and offers a second chance to reduce the risk of unintended pregnancy.
INSTRUCTIONS for the hormonal implant have been given to me, and I have been given the product information. I understand how the hormonal implant is inserted and removed. I understand the hormonal implant becomes effective within less than 24 hours after insertion if inserted within the first five days of a normal menstrual cycle and that it is effective for three years and needs to be removed by a clinician who has had experience removing hormonal implants. I understand it may be difficult to remove the hormonal implant. I have been instructed on the care of the area following insertion and the need for follow-up care.
I understand that the hormonal implant does not protect against sexually transmitted infections (STI’s).
DECISION NOT TO CONTINUE USING THE HORMONAL IMPLANT: I have been told that I may have my hormonal implant removed at any time by a qualified medical clinician. Removal will require local anesthesia and one small incision. There is usually an additional medical fee for removal. I understand fertility can return immediately after the rod has been removed.
INSERTION: The hormonal implant rod is about 4 cm long and 2 mm wide. It will be inserted just under the skin of your upper arm using the insertion device and that there may be a 1/8-inch incision. Local anesthesia is used before insertion to make the skin temporarily numb. Some bruising may occur in the insertion area but should disappear within a short time. The incision will be protected by a bandage for the first few days. The site usually will heal quickly. Minimal to no scarring is expected. You will be able to feel the hormonal implant, and it should be visible under the skin.
QUESTIONS: I have been given the chance to ask questions about the hormonal implant and about the consent form.
Client Signature _________________________________ Date _________________