FAMILY PLANNING PROGRAM INFORMED CONSENT FOR CONTRACEPTIVE METHODS (Prescription & Non-Prescription) ORAL CONTRACEPTIVES I have chosen oral contraceptives as my method of contraception. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of oral contraceptive use. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________
DEPO-PROVERA I have chosen Depo-Provera as my method of contraception. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of Depo-Provera. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________
NUVA RING I have choosen the Nuva Ring as my method of contraception, I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of Nuva Ring. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________
BARRIERS (Condoms, Foams, or Diaphragm) I have chosen to use a barrier as my method of contraception. I have been provided counseling and written information regarding the benefits, risks, effectiveness, potential side effects, and complications related to the use of this method. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________ INTRAUTERINE DEVICE (IUD) I have chosen the Intrauterine Device (IUD) as my method of contraception. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of the IUD. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________ IMPLANON I have chosen the Implanon as my method of contraception. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of the Implanon. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________
EMERGENCY CONTRACEPTION (PLAN B) I have requested Plan B for emergency contraceptive use. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of using Plan B. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________ ORTHO EVRA “The Patch” I have chosen Ortho Evra transdermal system as my method of contraception. I have been provided counseling and written information regarding the benefits and risks, effectiveness, potential side effects, complications, and danger signs of Ortho Evra transdermal system use. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________ NATURAL FAMILY PLANNING (CycleBeads) OR FERTILITY AWARENESS METHOD I have chosen to use Natural Family Planning for Fertility Awareness as my method of contraception. I have been provided counseling and written information regarding the benefits, risks, effectiveness and complications related to the use of this method. I have been given the opportunity to ask questions and I understand the information that has been provided to me. _________________________________
O Conselho do Governo, reunido no dia 26 de março de 2013, na Calheta, no âmbito da visita estatutária à ilha de São Jorge, tomou as seguintes deliberações: 1. Aprovar a atribuição de um apoio financeiro à Câmara Municipal da Calheta correspondente à componente não comparticipada por fundos comunitários das obras de reabilitação da rede viária municipal do concelho afetada pelas
PIEDMONT COMMUNITY SERVICES Assessment / Social History Identifying Information Presenting Problem, Onset and History of ProblemInformation pertaining to this assessment was gathered from the mother, client, and chart. Client is referred to IIH from case management due to demonstrating disrespectful behaviors towards peers and adults. The mother reports that client is exhibiting aggr