Coil Consent Form

Please complete this coil consent form as part of your care under the Kirkby Women’s Health Hub, providing LARC services to Kirkby:

*Only complete this form if you have been asked to by a clinician*

First Name

Surname

Date of Birth

Address

Street Address Address Line 2 City Postcode Country

What is the name of your GP practice? Select one of these options:

I request a

IUT – Intrauterine Therapy IUS – Intrauterine System (hormone coil) IUD – Intrauterine Device (copper coil)

I understand that I will not have unprotected sexual intercourse from my last menstrual period until IUT is fitted

I understand that I will not have unprotected sexual intercourse for 7 days following IUS fitting

I understand that the possible risks of IUT placement include infection, bleeding, allergic reaction, perforation at the time of insertion (pushing the IUT through the womb) and this may require emergency surgery, perforation months/ years after fitting which may require emergency surgery, expulsion (the IUT coming out), ectopic pregnancy (pregnancy outside the womb), vasovagal shock (fainting episode), failure to insert, failure to remove

I understand that I may have irregular bleeding and cramping after IUT insertion. Periods may become lighter and may stop with IUS. Periods may become heavier and more painful with IUD

I understand that IUT does not protect against sexually transmitted infections

I understand that after fitting I may experience cramps/ pain and spotting/vaginal bleeding. This may last for days after fitting

I confirm that I have read and understood the above information. I have been given the opportunity to ask questions. I voluntarily agree to IUT insertion. I understand that I can cancel the fitting at any point

I consent to the clinician at the Kirkby Women's Health Hub fitting my IUT