MIRENA IUD CONSENT
I have asked for and received information from _________________________ County Health Department.
I was told about all methods of birth control. I have received and read information on the Mirena IUD, a
hormone-releasing system to be placed in my uterus, and have chosen to use this IUD. I was told that the
decision to use the Mirena IUD is completely up to me. The discomforts, benefits, and risks with this
method have been explained to me and I have received the Mirena Information Sheet. All my questions
have been answered. I understand that no kind of birth control works every time for every woman using it.
I was told that I could have the IUD removed at any time I wish. I understand it must be removed at the
end of 5 years because after that it is no longer working. Then, if I still do not want to be pregnant, I may
choose the method of birth control I want at that time. I consent to the insertion of the Mirena IUD.
(Client signature) (Date)
STATEMENT OF PERSON OBTAINING CONSENT
Before the above client signed the consent form, I explained to her the procedure for IUD insertion,
discomforts, benefits and risks associated with it. I also explained the other methods of birth control. To
the best of my knowledge and belief she is mentally competent and knowingly and voluntarily requests the
Mirena IUD as a contraceptive method and understands the nature and consequences of its use.
(Signature/title of person obtaining consent) (Date)
I have interpreted the information and counseling presented orally to the client who has chosen to use the
Mirena IUD. I have also read to her the consent form in a language she understands and explained its
contents to her. To the best of my knowledge and belief she understands this and voluntarily consents to
the insertion of the Mirena IUD.
(Signature of Interpreter) (Date)
FAMILY PLANNING SERVICES TO MINORS
____ The minor was counseled on the desirability of parental consent, responsible decision-making,
sexual abstinence and how to resist coercion to engage in sexual activity.
(Check the applicable and sign)
____ The minor is married, is pregnant or is a parent.
____ The minor has parental permission to receive contraceptive services. (signed permission slip
placed in record)
____ It is my opinion that this minor may suffer probable health hazards if contraceptive services
are not provided.
(ARNP, PA, DO, or MD signature) (Date)