Name of Procedure

Implanted Birth Control 2017 Page 1 of 4

Implanted Birth Control (Nexplanon®)

Educational Material and Consent Form

Patient name ______

Facility name______

Name of provider conducting informed consent______

Your Health Condition

You do not want to get pregnant. There are many birth control choices, but you and your doctor think that gettingimplanted birth control is a good choice for you.

Implanted birth control is a small plastic rod the size of a match. It is placed under the skin. Itreleases a chemical that is also made in your body. This chemical prevents your ovaries from releasing eggs. It also stops mucus in your cervix from getting thick. This helpsstop sperm from reaching an egg and fertilizing it.

Implanted birth control will work for about three years. After that, itshould be removed. You can then get a new implant if you want.

The Procedure and Follow Up

This procedure will take place in your doctor’s office.

You will lie down and raise your arm above your head. You will get a shot of numbing drug on the inside of your upper arm. Your doctor will use a special tool to push the implant through a needle and under the skin. This will take a few minutes. After the procedure, you will get a bandage over the site.

If you getthe implant during the first five days of your period, you will be protected from getting pregnant. If it is placed before or after the first five days or your period (or if you are unsure about this), you should usesome other form of birth control for two weeks.

Risks and Common Problems

There are risks linked to this procedure, which include but are not limited to:

Allergic reaction: All kinds of allergic reactions can happen. You could have a minor reaction such as a rash or a severe reaction such as swelling of your tongue or throat. A severe allergic reaction is a medical emergency that can cause death.

Bleeding: You could have a little bleeding at the site.

Ectopic pregnancy: If you get pregnant, there is a higher risk for a pregnancy to happen outside of the uterus in the fallopian tube. This is also called a tubal pregnancy. This could be a threat to your life, and you may need surgery. Your fallopian tubes or ovaries could also be harmed.

Infection: You could get a sickness caused by germs. If this happens, then you will need to be treated with drugs that kill germs or slow their growth.

Irregular bleeding: Your periods may not be regular, mainly in the first six to twelve months after the procedure. Most women’s periods get lighter and less painful. They may even stop. Sometimes, periods can get heavier.

Local effects: At the site of the shot, you could havepain, swelling, or bruising.

Movementproblems: An implant could move and become hard to take out.

Side effects: After theprocedure, you could have headaches, a dizzy feeling, a sick feeling in your stomach, sore breasts, weight gain, sad mood, or acne. You could also have extra hair growth and dark spots on the skin, especially on the face. These problems are rare.

If any of the problems listed above happen to you, then you may need to have more treatments or procedures. This means you may need to go to the hospital.

Other Choices

If you choose not to get implanted birth control, you may have other choices. You may decide to use some other kind of birth control, such as:

pills, patches, or a shot,
an intrauterine device (IUD),
rings, sponges, a cervical cap, or a diaphragm,
condoms,
surgery, or
not having sex.

Your doctor will let you know what other choices may be best for you. How well any other treatment works will depend on your specific health condition.

More Facts

Implanted birth controlworksmore than 99% of the time.

Many women like implanted birth control because:

it can be used while breastfeeding,
it can be used in women who cannot take estrogen, and
it means you do not have to worry about taking a pill or inserting a device before having sex.

If you change your mind about implanted birth control, you can have it taken out at any time.Your fertilityshould return to normal. Taking out the implant takes longer than putting it in. Most of the time, this takes less than 20 minutes.

Nexplanon®will not work formore than three years.After three years, you must use a different kind of birth control or get a new implant put in.

Implanted birth control does not protect against sexually transmitted infections (STIs). Only a condom can help prevent these infections.

Some drugs can cause problems and make implanted birth control not work as well. These include drugs used to treat infections, mental illness, seizures, tuberculosis, HIV, or migraine headaches. Some herbs can cause the same problems.Talk to your doctor if you need to take any of these drugs.

You should not get implanted birth control if you are pregnant, have liver disease, or have breast cancer.

Other doctors and skilled medical personnel may help your doctor. They will follow state laws and rules from their health care facilities about what duties they may do.

Consent to Treatment

____Patient Initial The first three(3) pages of this form told you the risks, likely results, other choices, and problems that could happen with implanted birth control. If, after you have read and reviewed this form with your doctor, you do not believe that you really understand the risks, likely results, other choices, and possible problems of implanted birth control, do not sign the form until all your questions have been answered.

I have ___ no known drug allergiesor ___ the drug allergies listed below:

______

I understand all the facts given to me in the first three(3) pages of this form. I give my consent to Dr. ______and his/her associates to give implanted birth control to me. By signing below, I agree that: my doctor has discussed all of the facts in this form with me, no one has given me a guarantee about success or outcome, I have had a chance to ask questions, and all of my questions have been answered.

______

Signature of Patient or Responsible PartyDate and Time

______

Relationship to Patient (if Responsible Party is not Patient)

______

WitnessDate and Time

Note to Witness: You have been asked to witness this procedure-specific informed consent. By witnessing this form, you are acknowledging that you have asked and the patient has confirmed to you that she:

has read the whole form,
understands the form as it is written,
understands no guarantees have been made about success or outcome,
has had her questions answered, and
chooses to carry on with the doctor’s recommended procedure.

Physician: I confirm with my signature that I have given the patient three (3) pages of educational material and have discussed with the above-named patient the risks, likely results, other choices, and possible problems of implanted birth control. I have made no guarantees about success or outcome. The patient has had the chance to ask questions, all questions have been answered, and she has expressed understanding. Thus informed, the patient has asked that I give implanted birth controlto her.

______

Physician SignatureDate and Time

______

Witness Date and Time