IUS Consent Form

 
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Patient Details
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Intended purpose of treatment
Tick those that apply:
Possible adverse effects
  • Although a highly effective means of preventing pregnancy, the IUS or mirena is not 100% effective
  • Because of the way the IUS works, the periods will be very likely to change. For the first few weeks after insertion, it is normal to experience regular light shedding of blood or spotting which will usually settle after 12 weeks. After this time, the periods may become very light and often there will be only very occasional bleeding.
  • There is a small increase in the risk of infection for the first 20days after insertion
  • There is a small risk (less than 1 in 20) of the device later being pushed out (expelled) by the womb or moving
  • Occasionally due to stimulation of the nerves to the cervix during the procedure, there can be a temporary episode of faintness (cervical shock).
  • During the insertion procedure, there is a very small risk (about 1:1000) of the IUS going through the womb (perforation)
  • Hormonal effects have been associated with the mirena/IUS such as greasy skin/weight change and mood change. 
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Patient Statement

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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