Deep implant referral form

Your information

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Deep implant referral form

Client details
Name*
Firstname Surname
Address*
Address line 1 Address line 2 City County Postcode
Date of birth*
Contact number*
Referrer/GP details
Referred by
Name of GP*
Firstname Surname
GP address*
Address line 1 Address line 2 City County Postcode
Contact number*
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 appropiate 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.

Deep implant referral form

Your information

Deep implant referral form

Client details

Referrer/GP details

Referral questions

Consultation