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Get IUD Consent 2013-2024

XXXXXX Health Center Address Phone IUD Consent form I request a circle one / Skyla / IUD I understand the following I will have a pregnancy test before the IUD is inserted. If I had unprotected sex within the past 7 days the pregnancy test may not be accurate and may read negative when an early pregnancy is starting. With the and Skyla IUDs my periods may get lighter or disappear and I understand that this is not dangerous. With the IUD may periods may get heavier or last longer. I may check the strings of the IUD once a month to make sure it is in the right place. I will come into the office to have the IUD checked if I can t feel the strings. I have been given a patient information form to take home about the side effects to expect after the IUD is inserted. I hereby consent that insert the IUD for me. The may be used as Emergency Contraception for up to 5 days of after unprotected sex The protects against pregnancy for 5-7 years. The Skyla protects against pregnancy for 3 years. The protects against pregnancy for 1012 years. The possible risks of IUD placement include infection bleeding allergic reaction perforation of poking a hole in the uterus and expulsion falling out of the IUD. I may have irregular bleeding and cramping for the first 3 months after the IUD is inserted* Ibuprofen or a heating pad may help with these symptoms. With the and Skyla IUDs my periods may get lighter or disappear and I understand that this is not dangerous. With the IUD may periods may get heavier or last longer. I may check the strings of the IUD once a month to make sure it is in the right place. I will come into the office to have the IUD checked if I can t feel the strings. I have been given a patient information form to take home about the side effects to expect after the IUD is inserted* I hereby consent that insert the IUD for me. Signature of patient Date Signature of provider Date Witness Date February 2013 / www. reproductiveaccess. The may be used as Emergency Contraception for up to 5 days of after unprotected sex The protects against pregnancy for 5-7 years. The Skyla protects against pregnancy for 3 years. The protects against pregnancy for 1012 years. The Skyla protects against pregnancy for 3 years. The protects against pregnancy for 1012 years. The possible risks of IUD placement include infection bleeding allergic reaction perforation of poking a hole in the uterus and expulsion falling out of the IUD. The possible risks of IUD placement include infection bleeding allergic reaction perforation of poking a hole in the uterus and expulsion falling out of the IUD. I may have irregular bleeding and cramping for the first 3 months after the IUD is inserted* Ibuprofen or a heating pad may help with these symptoms. I may have irregular bleeding and cramping for the first 3 months after the IUD is inserted* Ibuprofen or a heating pad may help with these symptoms. With the and Skyla IUDs my periods may get lighter or disappear and I understand that this is not dangerous.

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