Request For Progestin-Only Birth Control Shots Form (Page 2 of 2) in pdf

This usually gets better over time. However, after one year of use at least 50% of women do

not get their periods. Other possible side effects include weight gain, headaches, breast

tenderness, hair loss, and other effects such as loss of sexual desire, depression, and fatigue.

Will Depo Provera hurt my chances of getting pregnant in the future?

Birth control shots are not a permanent form of birth control, so you will be able to get

pregnant when you stop getting the shots. Studies show that it may take an average of 9 to

10 months for a woman to get pregnant after she has had her last shot. This means that it may

take longer to get pregnant after you stop using Depo Provera than if you had used another

kind of birth control. A woman's ability to get pregnant after using Depo Provera depends on

many things, including her ability to get pregnant before she used Depo Provera.

Does Depo Provera protect against AIDs and STDs?

Birth control shots do not protect against HIV, the virus that causes AIDS, or against sexually

transmitted diseases (STDs). Women at risk of HIV/AIDS or STDs should use a female condom

or a male latex condom in addition to Depo Provera to prevent disease. If you or your partner

is allergic to latex, use polyurethane condoms. Your healthcare provider can help you decide if

you are at risk of HIV/AIDS or STDs.

How often do I need to get Depo Provera shots?

Depo Provera shots should be given every 12 weeks. If you cannot keep your appointment for

your next shot of Depo Provera, call your healthcare provider. If you are late getting a shot, you

may need a pregnancy test before you get another shot.

You should call the clinic to receive follow-up and counseling for:

- severe headaches

- heavy bleeding

- depression

- severe pain in your lower abdomen

- infection or pain around the part of your body where you got your shot of Depo Provera.

If you have any questions about birth control shots, ask your healthcare provider.

I have read and understand the above information.

Patient Signature: ___________________________________ Date: _______________________

The client has been counseled, provided with the appropriate informational material, and

understands the content of both.

Counselor/Provider signature: __________________________ Date: ______________________

Print counselor/provider name: _____________________________________________________

Name of patient: _______________________ Date of Birth: _________ Chart #:____________

Interpreter: _______________________________________________________________________

REQUEST FOR FOR PROGESTIN-ONLY BIRTH CONTROL SHOTS

Request For Progestin-Only Birth Control Shots Form Page 2