Deep implant referral form

Your information

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Deep implant referral form

Client details

Name(Required)

Firstname Surname

Address(Required)

Address line 1 Address line 2 City County Postcode

Date of birth(Required)

Contact number(Required)

Referrer/GP details

Referred by

Name of GP(Required)

Firstname Surname

GP address(Required)

Address line 1 Address line 2 City County Postcode

Contact number(Required)

Referral questions

Insertion date

If unknown approximate length of time implant in place

Which arm?

Left

Right

Assessment history

Is the Implant palpable? Or non-palpable?

Attempt made to remove it? If so, when?

Allow at least 1-2 weeks for the wound to heal before attempting again.

Has it ever been palpable?

Why is the implant being removed?

Brief medical history/medication/allergies

Additional information

Please note. Unless the Implant is being removed for a planned pregnancy, please start an ongoing method of contraception before removal.

Consultation

Clinicians to discuss the following and tick appropriate box during consultation:

Inform the patient that although best effort will be given to remove it at this appointment, it may not be possible. The patient may have to go to Canterbury or to a plastic surgeon for very difficult removals.

Inform the patient that if they are more than 10 minutes late for their appointment it may have to be rescheduled.

Advise the patient not to bring children to this procedure appointment.

Request an interpreter for the patient, if needed.

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Deep implant referral form

Your information