Please review the information below. Ask questions of your health care provider to ensure that you
understand the risks and benefits of using the IUD.
The IUD is one of the most effective birth control methods available. Fewer than 1/100 people per
year using the IUD will get pregnant.
Advantages of using the IUD include:
** Highly effective and long-lasting contraception.
** Low risk of side effects.
** Reversible (immediate return to fertility after removal).
** Decreased menstrual blood loss (Hormonal IUDs).
** Good safety record.
** High satisfaction rates.
Potential side effects/risks of IUD use:
** Mild to moderate pain when the IUD is inserted.
** Cramping or backache for a few days after insertion.
** 2-10% of IUD users spontaneously expel their IUD within the first year of use.
** Irregular or absent menses (Mirena, Kyleena and Skyla).
** Heavier, longer and/or crampier menstrual periods (Paragard IUD) which may improve with
time. Spotting between menses which usually improves or resolves within 3 months (both
Hormonal IUDs and Paragard IUD).
** Anemia (only if heavy menses occurs).
** Acne. Hormonal IUDs, like other methods of hormonal birth control may cause or worsen
acne.
Serious but very infrequent risks of IUD use:
** Infection of the uterus or tubes {pelvic inflammatory disease (PID)} within the first 3 weeks
after the IUD is inserted. If PID is not treated, infertility could result.
** While pregnancy with an IUD in place is rare, if you are pregnant, you are at increased risk
of an ectopic pregnancy (pregnancy outside of the uterus) which can be life threatening if
not treated.
** Perforation of the uterine wall during IUD placement or embedment in the uterine wall (rare,
surgery may be required.
At the time of insertion, there is a possibility that the cervix will be tightly closed and not allow for
insertion of the IUD into the uterus. Another visit may need to be scheduled. You may be asked to
return while on your period or after taking a medication to soften your cervix to improve success of
insertion.
It is also possible that dilation of your cervix may need to be performed.
The IUD does not protect against HIV (the virus that causes AIDS) or other sexually transmitted
infection (STIs). Using a condom correctly and consistently helps prevent STIs.
It is important to avoid unprotected intercourse between your last menses and the IUD insertion to
minimize your risk of pregnancy and infection.
I may elect to have the IUD removed at any time. A visit with a health care provider is needed to
have the IUD removed.
An alternative method of contraception should be used if the IUD strings cannot be located.
Emergency care is always available if you should need it. Check the eTang Portal for more
information.
I have reviewed the Paragard, Mirena, Kyleena and Skyla Patient Information handouts. I have
been informed of the IUD insertion and removal procedure and what to expect when the IUD is
inserted and know I should check the strings regularly.
I have reviewed and understand all of the above information. I have been given the opportunity to
ask questions and have had them answered to my satisfaction. After reviewing the above
information, I hereby authorize and direct my clinician to insert the IUD when my clinician and I
have agreed is
appropriate for me.
I understand and agree that I am financially responsible for the payment I made for
that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the
date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months
period. I agree that my payment made is non-refundable or non-transferable post this period.
"I agree that healthcare provider(s) involved in my care at this facility will access my health information
through the Health Information Exchange System (NABIDH) in accordance with the Laws of the United Arab
Emirates, Emirate of Dubai Legislation and Dubai Health Authority Policies ".
I declare that I have read and fully understood all points in this consent and that all of my questions were
answered to my satisfaction and I take the full responsibility of my decision in this consent.
Patient Name & Signature :
Doctor/Therapist Name & Signature :
Witness Name & Signature :
Parent or Gaurdian Name (if patient is minor) :
Date :
Consent to be photographed and published
I, , consent to be photographed and published on Social
media, by while before and after the procedure. I further authorize that the
photographs may be published for any purpose and in any form.
