Dhhs 4108 - Request And Consent For Mirena Levonorgestrel Releasing Intrauterine System
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1
2N.C. Department of Health and Human Services
1. Last Name
First Name
MI
Division of Public Health
Women's and Children's Health Section
Family Planning and Reproductive Health Unit
2. Patient Number
3. Date of Birth
(MM/DD/YYYY)
Request and Consent for Mirena
®
Month
Day
Year
□
□
Levonorgestrel Releasing
4. Race
American Indian or Alaska Native
Asian
□
□
Black/African American
Native Hawaiian/Other Pacifi c Islander
□
□
Intrauterine System
Unknown
White
□
□
5. Ethnic Origin
Hispanic Cuban
Hispanic Mexican American
□
□
Hispanic Other
Hispanic Puerto Rican
□
□
Not Hispanic/Latino
Unreported
□
□
6. Gender
Female
Male
7. County of Residence
Voluntary Participation and Confi dentiality Statement: Title X services are provided solely on a voluntary basis. Individuals must not
be subjected to coercion to receive services or to use or not to use any particular method of family planning. Acceptance of family planning
services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance from or participation in any other programs
of the applicant. This information is confi dential and will be treated as such.
Birth control methods may have good or bad side effects or complications, which may be harmful to me. I have been told that the most
frequent benefi ts, risks and side effects are those listed below. Others not listed may occur.
Mirena® (Levonorgestrel IUD) Use Effectiveness: 99.8 Percent
Benefi ts
Possible Risks/Disadvantages
Possible Side Effects
1. Highly effective contraception
1. Infections occur within the fi rst few days after
1. Altered menstrual period fi rst few
lasts fi ve years
Insertion (rarely)
months after insertion
2. Gives freedom for greater sexual
2. IUD may go through the uterus. This is called
spontaneity
perforation.
3. Cost effective
3. The IUD may come out by itself (expulsion). Use of
a backup birth control method would be required for
4. Decreased risk of ectopic
expulsion.
pregnancy
4. Missing IUD threads/strings—your provider can
5. Less blood loss during periods
usually remove an IUD with missing threads in
6. Convenient
the offi ce. Rarely, you will need minor surgery to
remove an IUD with missing threads.
5. No protection from sexually transmitted diseases
including HIV
Contraceptive Technology 20
ed. 2011
th
1. I do not wish to become pregnant now. One benefi t of choosing a method of birth control is that I will be better able to delay a pregnancy
until it is desired.
2. All contraceptives offered by this clinic have been explained to me. I may change to another method if medically recommended. Also, I
may stop using a birth control method if I wish to become pregnant. Instructions for the use of my chosen method have been given to me.
3. I understand that to continue the use of the Mirena® IUD, I must come to the clinic for my yearly check up. It is my responsibility
to schedule my yearly health check. I also understand it is my responsibility to check for IUD strings monthly and call my healthcare
provider if I am unable to locate the strings.
4. I understand if any of the following danger signs occur severe abdominal pain, unexplained fever or fever after insertion, pelvic pain or
pain during sex, unusual vaginal discharge, genital sores, cannot feel the IUD strings, have severe or prolonged vaginal bleeding, or if
partner has sexually transmitted disease, I know to seek medical attention immediately.
DHHS 4108 (Revised 8/2016)
Family Planning and Reproductive Health (Review 8/2019)
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