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Northeast iowa community action corporation

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.
_________________________________

Source: http://neicac.org/forms/fpforms/InformedConsentForContraceptionEnglish.pdf

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