• Contraceptive Implant Removal Appointment Request Form

    Request an appointment for contraceptive implant removal and share the details the clinic needs to review your request.

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Appointment Request Details

  • Preferred appointment date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred appointment time
  • How urgent is this request?*

  • Contraceptive Implant Details

  • Approximate insertion date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you know the implant brand or type?*
  • Is this request for removal only or removal with replacement?*

  • Reason for Removal and Current Concerns

  • Reason for removal*
  • Current symptoms or concerns

  • Medical History and Safety Screening

  • Known Allergies
  • Could you be pregnant?
  • Do you have a bleeding disorder or take blood thinners?

  • Scheduling Notes and Consent Acknowledgment

  • Acknowledgment*
  • Should be Empty:
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