Contraceptive Implant Removal Form

If you would like to have a Contraceptive Implant removed please fill in the online form here.

Your First Names

Your Last Name

Your Date of Birth

Your Phone Number

Your Email

I am aware that as soon as the implant is removed there is a risk of pregnancy

I am aware that I may need to use additional contraception after removal if required

I am aware that I will seek medical advice if worsening pain or fever in or around the site of removal

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Little Harwood Health Centre • Plane Tree Road, Little Harwood, Lancashire, BB1 6PH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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