XXXXXX Health Center
Address:
Phone:
____ I request a (circle one): Mirena / Paragard 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.
____The Paragard may be used as Emergency Contraception for up to 5 days of after unprotected sex
____ The Mirena protects against pregnancy for 5-7 years. The Paragard protects against pregnancy for 10-12 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 Mirena IUD my periods may get lighter or disappear and I understand that this is not dangerous.
____ With the Paragard 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:____________
