INTRAUTERINE DEVICE (IUD) REMOVAL CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I am requesting the removal of an intrauterine device.
* I have been informed and understand that the contraceptive effect stops immediately.
* I understand that if I am in the middle of my menstrual cycle and have been sexually active during the week before removal, there is a risk of pregnancy.
* I have been informed of and understand the possible side-effects and complication of IUD removal.
* There may be some cramping/pain or bleeding.
* If the treads are no longer visible, or they break during the procedure, I may require a scan or need to be referred to another provider to have the IUD removed.
* I have been given the opportunity to ask questions.
* I give the consent for the IUD removal.

* I give consent for health professional who is training in this skill to do the removal.

I have talked about the side-effects and complications of an IUD removal, and have explained that the contraceptive effect stops immediately. I have given the patient the opportunity to ask questions.

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.

Patient Name & Signature :