Provider: Check Appropriate Section(S) to Be Reviewed and Completed by Patient

DEPT. OF OB/ GYN AND REPRODUCTIVE
SCIENCES
INTRAUTERINE CONTRACEPTION (IUC) PLACEMENT CONSENT FORM / NAME
DOB
MRN
PCP
Patient ID / Addressograph

Provider: Check appropriate section(s) to be reviewed and completed by patient.

Patient: Initial to indicate that you have read and understood each statement in the checked sections.

þ Information for all

______I know I need to check my IUD strings every month to be sure the IUD is still in my uterus.

______I understand the serious risks from IUD placement (including perforation of the uterus, possible need for surgery).

______I understand that I may have my IUD removed by a health care provider at any time for any reason.

______I must have my IUD removed or replaced in ____ years, or by ____/____/____.

o Copper T380A (Paragard®)

______I know that the IUD may make my periods heavier or crampier, and that I may spot between periods.

o Levonorgestrel IUD (Mirena®)

______I understand that my IUD contains the hormone levonorgestrel.

______I know that I may have irregular bleeding or spotting or that my periods may stop altogether.

______I understand that the hormone in the IUD may have the additional side effects, such as breast tenderness, headaches or
moodiness.

o Post-Abortion IUD insertion

______I understand that if I am found to have an infection with gonorrhea or chlamydia (sexually transmitted diseases), I will
need to follow up for treatment.

______I understand that because my gonorrhea and chlamydia results are not available at the time of the IUD insertion, if I
have a sexually-transmitted infection today I may be at increased risk for pelvic inflammatory disease (a pelvic
infection that can be severe and result in infertility or hospitalization). This could happen even though I will receive a
medicine that can prevent pelvic infection. Pelvic infection risk may be lower if I have the IUD inserted after I know

the results of my tests and have been treated for gonorrhea or chlamydia.

______I understand that because the cervix will be open in order to complete the abortion, I may be at an increased risk that
the IUD may fall out and if it does, I will not be protected against pregnancy.

______Despite these possible risks, I would like the IUD placed at the time of my abortion. I understand that if I don’t have an
IUD placed today, I can still have one inserted at another time.

______I know I must have a follow-up appointment with a doctor or nurse in about 3 weeks to check that the IUD is still in my
uterus and to trim the strings if necessary. I should not have sex until after that appointment.

þ All to complete

I have read information about the IUD and discussed my choice with my clinician. My clinician has answered all my questions and has advised me of the risks and benefits associated with the IUD, with other forms of contraception, with no contraception at all, and with having the IUD placed at a later date.

I have considered all these factors and voluntarily choose to have the (check one)  Paragard®  Mirena® IUD inserted.