INGHAM COUNTY HEALTH DEPARTMENT

Family Planning Services

IMPLANON CONSENT

IMPLANON is a single rod progestin-only implant that is effective for up to three years. It is inserted subdermally (under the skin) in the inner aspect of the upper arm. It is a flexible plastic rod 4 cm in length and 2 mm wide. Implanon does not contain latex and is not radio-opaque. Implanon works primarily by inhibiting ovulation. It also thickens cervical mucus. Implanon must be inserted and removed by a manufacturer approved trained health care professional.

I am voluntarily requesting to have an Implanon inserted as a method of pregnancy prevention. I am aware that Implanon is not guaranteed to be 100% effective, but is over 99% effective.

Advantages of the Implanon:

- Highly effective

- Convenient (nothing to do before sex)

- Long lasting (three years)

- Can be used with breastfeeding.

Disadvantages of the Implanon:

- Irregular bleeding

- I may also experience some of the following side effects: Headache, vaginitis, weight gain, acne, breast pain, viral infections, stomach pain, painful periods, mood swings, nervousness, or depression, back pain, nausea, dizziness, pain, pain at the insertion site.

I understand I should not use Implanon if I am pregnant or thinking of becoming pregnant, have or have had a serious blood clot, (in leg, lung, retina, or heart attack). I should not use if I have unexplained vaginal bleeding, have liver disease, have breast cancer now or in the past, or if I am allergic to anything in Implanon.

Risks of Implanon :

- Complications of insertion and removal

Pain, irritation, swelling, or bruising, Scarring, Implanon breaks making removal difficult, rarely expulsion of the implant, rarely need for surgery in the hospital for removal of Implanon. Removal of deeply inserted implants can lead to scarring or complications. This includes a thick scar called a keloid.

- Ectopic Pregnancy

- Interaaction with other Medications such as barbiturates, griseofulvin, rifampin, phenylbutazone, phenytoin, carbamazepine, felbamate, oxcarbazepine, topiramate, and modafinil. Herbal remedies such as as St John’s Wort.

I understand that I cannot have Implanon if I have a history of blood clots, breast cancer, am pregnant or planning a pregnancy.

I understand that Implanon does not protect me against HIV or other sexually transmitted infections.

Alternatives: Other birth control options have been explained to me.

Discontinuing Implanon: I understand that I may have the Implanon removed after three years or if I desire earlier.

I have been given the chance to ask questions about the Implanon and other method of birth control.

Patient Signature:______Date:______

Counselor Signature:______Copy to Pt.______

If you have questions or concerns, call the center: (517)887-4320.