IUS / IUD - Before fitting checklist

Please type the name of the clinic where you have booked your IUD / IUS appointment

I have watched the online video on IUD/IUS or read the leaflets or I already have an IUD/IUS and am familiar with the method

I am using an effective method of contraception and haven't had any problems (eg split condom, missed pills, IUD/IUS overdue for change). I have not had any unprotected sex (or used withdrawal) since my last period.

I understand that it is not safe to insert an IUD/IUS if I might be pregnant

I will make sure that I have had breakfast/lunch on the day of the appointment (a painkiller can be taken around an hour in advance)

I am having a Chlamydia / Gonorrhoea test at my IUD/IUS fitting or I am up to date with STI screening

I understand that no method is 100% effective and that the IUD/IUS has a small risk of failure (less than 1 in 100)

I understand that there is a 1-2 in 1000 risk of perforation of the uterus at the time of insertion of the device

I understand that there is a 1 in 20 chance of the device falling out

I understand that the IUD/IUS will not protect against STIs

I understand there is a small increased risk of infection in the first three weeks following insertion of the device

I know if I chose a copper device that it will make my periods slightly heavier, longer and potentially more painful

I know that if I chose an IUS, it will make my periods much lighter but can cause irritatic bleeding and spotting in first few months of use

Please type your full name

Please type your date of birth

I consent for my information to be used for the purposes of providing healthcare for me and i consent to Liverpool University Hospitals NHS Foundation Trust processing and storing my submitted data.

• YES I consent
• NO I DO NOT Consent (please do not submit form and contact the service)