Mirena consent form 2026

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4.8 out of 5

166 votes

The document is an IUD consent form from the XXXXXX Health Center, outlining the patient's request for an IUD (Mirena, Skyla, or Paragard) and detailing important information regarding pregnancy testing, usage as emergency contraception, duration of effectiveness, potential risks and side effects, and post-insertion care. It includes sections for patient and provider signatures.

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Click ‘Get Form’ to open the Mirena consent form in the editor.
Begin by selecting your preferred IUD option by circling either Mirena, Skyla, or Paragard. This is crucial for ensuring you receive the correct device.
Review the information provided about pregnancy tests and emergency contraception. Acknowledge your understanding by checking the box next to each statement.
Read through the potential risks associated with IUD placement. It’s important to be informed before proceeding.
Fill in your name where indicated for consent regarding who will insert the IUD. Ensure this is accurate.
Sign and date the form in the designated areas for both patient and provider, as well as a witness if required.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (166 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do you have to be certified to place an IUD?

The FDA requires all who insert or remove the implantable contraceptive to be educated and trained on the product. Once completing an Organon Clinical Training program, a certificate is sent to the provider with a copy to the Specialty distributors.

What makes you ineligible for an IUD?

You shouldnt use copper IUDs if you have a copper allergy or Wilson disease, a genetic condition that causes copper to build up in your body. You shouldnt use hormonal IUDs if you have severe liver disease or cancer. You shouldnt use them if youre considered high-risk for cancer.

How do you get approved for an IUD?

If your nurse or doctor says an IUD is safe for you, you can get one. Most of the time, you dont need parent permission to get birth control, like IUDs. But the laws are different in every state. There are certain places where your nurse or doctor can contact a parent or guardian if youre under 18.

Do you need parental consent for an IUD?

Can I get birth control? Yes. California Family Code 6925 allows for minors to receive birth control without parental or guardian consent. There is also no age restriction and the health care provider is not allowed to inform a parent or legal guardian without the minors consent.

What are the requirements for IUD insertion?

Insertion of the IUD can take place at any time during the menstrual cycle provided the woman is not pregnant. Before insertion, a bimanual examination and a sounding of the are necessary to determine the position and the depth of the uterine cavity.

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Do you need a script for a Mirena?

IUD insertion Your doctor or nurse practitioner will write you a script and you can get the IUD from a pharmacy. Sometimes you can buy a copper IUD from the clinic providing the IUD insertion. The IUD is inserted inside your by a trained doctor or nurse.

How to consent for IUD?

I have reviewed and understand all of the above information. I have been given the opportunity to ask questions and have had them answered to my satisfaction. After reviewing the above information, I hereby authorize and direct my clinician to insert the IUD when my clinician and I have agreed is appropriate for me.

Is Mirena now approved for 7 years?

Over 99% effective at preventing pregnancy for up to 8 years. FDA-approved to decrease menstrual blood loss for up to 5 years in women who have heavy periods and choose an IUD for birth control. Supported by 2020-2022 SHS data.

Mirena consent form 2026

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