NEIGHBORHOOD FAMILY PRACTICE



NEIGHBORHOOD FAMILY PRACTICE

FAMILY PLANNING PROGRAM

INTRAUTERINE DEVICE (IUD) CONSENT FORM

• There are two types of IUDs, the Mirena and the Paraguard copper-T.

• The IUD keeps sperm from reaching the egg and/or by making the lining of your uterus thin. It may also stop release of your egg from the ovary.

• The IUD is 99% effective in preventing pregnancy.

• Side effects of the IUD may include cramping during insertion (both), increased bleeding during menses (Paraguard), ovarian cysts (Mirena), bleeding or spotting between periods (Mirena).

• Rare but serious health risks associated with IUD insertion can include uterine puncture or infection. If you become pregnant with the IUD, miscarriage is possible. If you experience any of the following symptoms, contact a clinician as soon as possible:

• Severe cramping or increasing pain in the lower abdomen that may be associated with feeling faint; pain or bleeding during sex; unexplained fever or chills; bad-smelling vaginal discharge; a missed, late or unusually light period; unexplained vaginal bleeding.

• The IUD does not protect against HIV and other sexually transmitted diseases.

• The IUD must be inserted and removed in a medical provider’s office.

• The Mirena IUD may stay in the uterus for up to 5 years and the Paraguard copper-T IUD may stay in the uterus for up to 10 years.

I have received a fact sheet from Neighborhood Family Practice containing information on the use, effectiveness and known risks of either the Mirena or the Paraguard copper-T IUD.

I have read the fact sheet or it has been read to me.

The information on the fact sheet has been explained to me.

I have been given an opportunity to ask any questions I have.

PATIENT

SIGNATURE:_________________________________________DATE:____________

I witness that the above person received and examined the fact sheet and this consent form. She states understanding. This consent form was signed in my presence.

WITNESS:______________________________________________________________

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