Westbourne Medical Centre consent form

Patient agreement to treatment

Name of procedure

Insertion of intrauterine contraceptive system (Mirena)

Statement of health professional

The intended benefits:

• To prevent unwanted pregnancy -- this is not 100% effective

Serious or frequently occurring risks:

• There is a very small chance of getting an infection during the first 20 days after an IUS is put in.
• The IUS can be pushed out by your womb (expulsion) or it can move (displacement).
• There is a very small risk that an IUS might go through (perforate) your womb or cervix when it is put in.
• If you do become pregnant while you are using an IUS there is a small increased risk of you having an ectopic pregnancy

I have confirmed that the patient has read “Your guide to the IUS” and have given her the opportunity to ask any questions.

Signed:     .........……………………………………   Date  ..........................

Name (PRINT) ………………………..……….       Job title ………………………………………….

Statement of patient

• I have read “Your guide to the IUS”
• I agree to the procedure described above.
• I understand that the person performing the procedure will have appropriate experience.
• I understand that the procedure will not involve anaesthesia.
• I confirm - that I have been using alternative contraception or avoided intercourse since my last normal period      

Signature ……………………………………….     Date    ............................

Name (Print) ........................................................         

This form will be scanned into your medical records.  If you would like a copy, please ask at reception.