IUD Consent Form

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Please only complete this online consent form if you have been asked to by a clinician following a consultation. If you don't understand anything in this form, then please book another appointment with a GP to discuss it further.

Personal Details
Pre-Consent Information

If you are interested in having the IUD (copper coil) or IUS (Mirena coil) please read the following information

Copper Coil IUD

Mirena Coil IUS

This information is provided by Sexwise.org.uk

If you have not informed your GP then please contact the surgery to make an appointment to discuss this.

Method of Action
Effectiveness
Duration
Procedure

It is advised that you take oral Analgesia (eg. paracetamol/ibuprofen) 1 hour prior to the coil fitting.

Side Effects & Risks
 
Pregnancy Risk Statement

If you:

Are using Condoms or are having unprotected sex: abstain from sex from the start of your period prior to your IUD fitting appointment.

Have Irregular/absent periods: abstain from sex for 3 weeks prior to the fitting appointment and do a home pregnancy test the day before your fitting.

Are using Hormonal Contraception: continue on your current contraception until the procedure (and ensure no missed pills/patches etc).

Have Long acting contraception (IUD/IUS/Implant) that has expired: abstain from sex for 3 weeks prior to the fitting appointment and do a home pregnancy test the day before your fitting.

Declaration

By Signing below I can confirm that I have having read and understood the above, I agree to the Insertion of the IUD/IUS

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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