Request & Consent For The Removal Of An Intrauterine Device Form printable pdf download

Request & consent for the removal of an

intrauterine device (IUD)

Please read this form carefully before you have your consultation with the doctor.

You should tick or mark the box next to each paragraph to indicate that you have read and

understood that section.

You will have the opportunity to discuss any specific questions or concerns that you may have when you talk with the

doctor

Please do not sign this consent form until you have spoken with the doctor.

Your name: ______________________________________________________

DOB _________________

Overview of treatment:

Your intrauterine device (IUD) will be removed by grasping the strings which are attached to it and pulling the

device out through your cervix (the neck of the womb). If your IUD appears to still be present within the womb on

an ultrasound examination, but the strings are no longer able to be seen in the cervix, special instruments will

need to be inserted through the cervix into the womb to hook onto the IUD and remove it. A sedation anaesthetic

may be required to make the removal process more comfortable.

Risks and side effects:

The removal of an IUD is often associated with some temporary discomfort and cramping.

There may be some vaginal bleeding after the removal of an IUD, and this bleeding is variable and generally

settles over a few days.

All IUD devices are reversible contraceptives, which means that your menstrual cycle will return to what is normal

for you over the following months.

Following the removal of an IUD, your fertility will also return to what is normal for you, and you will need to

consider alternative methods of contraception if you do not wish to become pregnant.

When your IUD is taken out, there is a risk of pregnancy if you have had unprotected sex during the 7 days before

the IUD is removed.

Some women who have a Mirena IUS taken out may notice some mood change for up to a few weeks after the

removal.

Intravenous anaesthetic drugs and/or local anaesthetic may be given to me to assist with the safe completion of

the removal procedure. If used, the sedation anaesthetic medications and some other drugs are given by

intravenous injection. These medication carry some risk, including allergic reactions, however these are rare.

Drug reactions may be potentially serious, but can usually be treated effectively with no long-term consequences

for the patient. It is important that you have had nothing to eat for 6 hours before the procedure and no water to

drink for 3 hours before the procedure. You must also tell the doctors about any existing health problems or

known allergies.

Additional, unforseen costs

It is sometimes necessary to arrange for additional diagnostic tests or for treatment at another facility by another

medical practitioner, in circumstances that were not foreseeable or not known to be needed at the time this

consent was given. You will be advised if any such tests or referrals are necessary, but you will be responsible

for any costs that may arise if this happens.

Do you have any specific concerns or questions? ………………………………………………………………………………………………..…………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………..

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Request & Consent For The Removal Of An Intrauterine Device Form