Coil Consent Form

 
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Patient Details
Processing
Patient agreement to Treatment

Procedure: Insertion of Intrauterine contraceptive Device (IUCD or coil)

Benefits of procedure: to prevent unplanned pregnancy

I understand that:

  • The IUCD although highly effective at preventing pregnancy is not 100% effective
  • There is a small chance of getting an infection during the first 20 days after the IUCD is inserted
  • The IUCD can occasionally be pushed out (expelled) by the womb or move position (displaced)
  • Occasionally due to stimulation of the nerves to the cervix during the procedure, there can be a temporary episode of faintness (cervical shock)
  • There is a very small (about 1:1000) risk of the IUCD going through the womb or cervix when it is being put in (perforation)
  • If pregnancy does occur despite having an IUCD, there is a possibility of this being an ectopic pregnancy because the IUCD cannot prevent the rare cases of pregnancy outside the womb.
  • The IUCD can commonly cause the periods to become heavier 
Patient Statement
Processing

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.

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.