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Upon making an IUCD Appointment, you will need to fill out this form.

IUCD Counselling Form

Obstetric History
Tick if any apply
Gynae History
Tick if any apply
Medical History
Tick if any apply
Tick if any apply
STI Risk
Tick if any apply

High Risk:

< 25 yo and sexually active

> 25 yo with:

1. A new Partner in the past year

2. >1 new partner in the past year

3. partner had >1 partner in past year

Leaflet Given

Procedure: Insertion of Intrauterine device

Patient Consent

I confirm that the information given by me is correct.

I have read the information leaflet on intrauterine devices.

The risks and side effects of the procedure and the device have been explained to me.

I understand the risk including perforation, expulsion, failure of insertion, failure of device, irregular bleeding, infection and pelvic pain.

I agree to the above procedure.

I would like to request a chaperone to my medical appointment

Thanks for submitting! We look forward to chatting with you!

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