Copper IUD

Please complete this form to request the copper IUD implant through your GP practice.

An IUD is a small, flexible plastic and copper device that’s put into your uterus (womb). It has one or two thin threads on the end that hang through your cervix (the entrance to the uterus) into the top of your vagina.

An IUD works for contraception for 5 or 10 years, depending on the type. If you’re aged 40 or older when the IUD is fitted, it will work for contraception until after the menopause, when contraception isn’t needed.

An IUD is sometimes called a ‘coil’ or ‘copper coil’. There are different types and sizes.

Please click the link below for more information on the copper IUD

https://www.nhs.uk/conditions/contraception/iud-coil/

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Date of birth *

Please use format day/month/year e.g. 12/05/1979

Email *

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One of our clinicians will contact you on this number in the next few days.

I have read an fully understand the side effects, effectiveness and complications of the implant.

I am aware that I need to use adequate contraception until device fitted, If not inserted on day 1 to 5 of cycle (day 1 being 1st day period) I need to use barrier methods or abstain for 7 days.

The doctor has explained I am to have the Copper IUD fitted for the following reason The Copper IUD is a contraceptive device which will be inserted inside the uterus through the vagina and cervix.

The Copper IUD offers effective and long-term contraception for 5 years and can be used as emergency contraception for up to 5 days after unprotected sexual intercourse. There are benefits and risks with all procedures. In signing this document, I agree that I have been informed of both the benefits and the risks of using the Copper IUD.

I acknowledge that the doctor has explained the proposed procedure. I understand the risks of the procedure and the likely outcome. The doctor has explained other relevant contraceptive options and their associated risks. I was able to ask questions and raise concerns with the doctor, which have been discussed to my satisfaction.

I hereby request to have the procedure and authorise Dr and such assistants to perform the insertion of the Copper IUD.

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Copper IUD

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