Procedure Consent Form: Nexplanon

Please review the information below. Ask questions of your health care provider to ensure that you understand the risks and benefits of using Nexplanon.

Nexplanon is one of the most effective birth control methods available. Fewer than 1/100 people per year using the Nexplanon will get pregnant.

The advantages of using the Nexplanon include:

Highly effective and long-lasting contraception Low risk of side effects

Reversible (immediate return to fertility after removal) Good safety record High satisfaction rates

The most common side effects of Nexplanon are:

Temporary pain at the site of insertion and/or skin bruising which will resolve with time Changes in menstrual bleeding pattern ranging from absence of bleeding to frequent and unscheduled bleeding and spotting (may improve over the first few months of use) A small scar after Nexplanon insertion and/or removal

Other potential but uncommon side effects:

Risks of Nexplanon use (rare):

Infection or pain in arm that may require antibiotics Difficult removal potentially requiring surgery which may cause pain, scarring, nerve and blood vessel damage While pregnancy with Nexplanon is rare, if you are pregnant you are at increased risk of an ectopic pregnancy (pregnancy outside of the uterus) which can be life threatening if not treated.

It is important to inform your healthcare provider that you are using Nexplanon as it may interact with other drugs you may be taking.

Nexplanon does not protect against HIV (the virus that causes AIDS) or other sexually transmitted infections (STIs Using a condom correctly and consistently helps prevent STIs.

It is important to avoid unprotected intercourse between your last menses and the Nexplanon insertion to minimize your risk of pregnancy.

You may elect to have the Nexplanon removed at any time. A visit with a health care provider is needed to have the Nexplanon removed.

Emergency care is always available if you should need it.

I have reviewed the Nexplanon information handout. I have been informed of the Nexplanon insertion and removal procedure and what to expect when the Nexplanon is inserted. Ihave reviewed and understand all the above information. I understand that this procedure requires the administration of local anesthesia. I also understand that the insertion procedure may leave a small scar and that an unpredictable reaction to local anesthesia can occur. I have been given the opportunity to ask questions and have had them answered to my satisfaction.

After reviewing the above information, I hereby authorize and direct my clinician to insert the Nexplanon contraceptive implant.