Consent for injection of depo provera for contraception

MORRIS COUNTY HEALTH DEPARTMENT
CONSENT FOR INJECTION OF DEPO PROVERA FOR CONTRACEPTION
Before you sign this form, be sure you understand the benefits as well as possible problems that might happen with use of Depo Provera. This form lists the possible problems and the danger signs you should watch for. You can change your mind at any time about using Depo Provera. I have received from Morris County Health Department (MCHD) information on the use and effectiveness and medically recognized benefits and risks of the other available birth control methods including abstinence. I understand the information and have had my questions answered. I understand that Depo Provera is given by injection (shot) and that it is a man-made hormone that is like the hormone progesterone which is normally made by a woman’s body. I understand that when I am using Depo Provera, the hormone lasts for about 12 weeks. I understand that Depo provera works by keeping the eggs from being releases from the ovaries and by making the mucus from the cervix (the opening from the womb) thick, so that it is hard for sperm to get through it. I understand the Depo Provera works to prevent pregnancy and that it is at least as effective as oral contraceptives when used perfectly. I understand that Depo Provera starts preventing pregnancy within 24 hours after it has been given, if it is given within the first 5 days after my period begins. I understand that at the end of 12 weeks I will no longer be protected from pregnancy. When I want to become pregnant, I understand that it takes an average of 9-10 months from the last injection to become pregnant and possibly up to a year or more. I understand that the advantages of using Depo Provera are: it prevents pregnancy, it lasts 12 weeks, there is no medication to take daily, there is nothing prior to intercourse to make it work I have been informed that I must not use Depo Provera if I am pregnant or think I might be pregnant. I have also been told not to use Depo Provera if I have any of the following: serious liver disease, any kinds of growths in the liver, abnormal bleeding from the vagina that has not been evaluated, known or suspected cancer of the breast, recent blood clots in the legs, lungs, or eyes, known allergy to Depo Provera I have been informed that some of my past or present conditions may increase my medical risk or make Depo Provera use unadvisable. I know to tell my clinician if I smoke or use any medications. I also know to tell my clinician if I have or have ever had any of the following: heart disease or stroke, diabetes, headaches, depression, seizure disorder (or if I am taking an anti-seizure medication), high blood pressure, recent history of liver disease (such as hepatitis0 or liver function tests that are not normal I understand that most women using Depo Provera experience a change in menstrual periods, including bleeding more days than usual, spotting between periods, no periods, or more than one of these changes. These changes are common particularly in the first 6 months of use. I understand that another possible problem or complication of using Depo Provera can include pregnancy in the tubes (ectopic pregnancy), in the rare chance that pregnancy does occur. I understand that I must call the clinic if I have problems while using Depo Provera. I understand that some rare but serious problems or complications have occurred with the use of birth control pills and although it is less likely that these problems or complications will occur with Depo Provera. Until more studies have been done on Depo Provera, I may also be at risk for the following: blood clots in my leg veins, heart attacks or strokes (if I smoke), growths in the liver, decrease in bone density I understand that cigarette smoking greatly increases the risk of serious cardiovascular side effects with oral contraceptives and that this risk increases after 35 years of age particularly if I smoke heavily (more than 15 cigarettes a day). It is not known if this happens with the Depo Provera therefore, I have been advised not to smoke cigarettes.
I understand that some women may also have the following other side effects with Depo Provera: change of appetite, weight gain, headache, sore breasts, nausea, abdominal discomfort, nervousness, dizziness, depression, Skin rash or spotty darkening of the skin, hair loss or increased hair on face or body,increased or decreased sex drive I understand that if I experience any of these side effects, there is no way to neutralize or reverse the Depo Provera and that the side effects may continue until the Depo Provera shot wears off. I understand that there may be less protection from pregnancy when using Depo provera and taking some other drugs at the same time including drugs to control seizures, certain antibiotics and others. I understand that I should talk to my doctor about what to do if I take any other medications while using Depo Provera. I understand that if I see a doctor for any reason I should tell him/her that I am using Depo Provera. Danger signs to watch for and report are: *sharp or crushing chest pain or coughing blood * shortness of breath * unusual swelling or pain in the legs or arms * sudden severe headaches *eye problems such as blurry or double vision or loss of vision * feeling dizzy or fainting * severe pain in the stomach or abdomen *yellowing of the skin or eyes *severe depression * heavy prolonged bleeding from the vagina I understand that the area where Depo Provera was injected might be sore for a day or two. I also understand that there might be a bruise or some soreness for a few days after it is injected. I understand that a clinician is available to answer sny questions I may have or to see me when needed. I understand that using Depo Provera does not protect me from sexually transmited diseases and a serious infection could travel up into my tubes and cause sterility. I understand that using barrier methods helps protect against certain STDs. I understand that if I or any of my sexual partners have sex with others, I should use a latex condom every time I have sex to keep from getting STDs even though I am using Depo Provera. I understand and agree that it is up to me to get extra and/or follow up care that may not be available from MCHD. No promises have been made to me as to the results which may be obtained if I use Depo Provera or any other method of birth control. I know I am to return for a checkup and another injection every 12 weeks and every year for a pap smear. Hereby request qualified personnel of MCHD to examine and treat me and that I be given Depo Provera. SIGNATURE OF CLIENT ____________________________________ DATE _____________________ STAFF SIGNATURE ________________________________________ DATE ____________________

Source: http://www.mrcohosp.com/mchforms/Health%20Department/Women's%20Health/CONSENT%20FOR%20INJECTION%20OF%20DEPO%20PROVERA%20FOR%20CONTRACEPTION.pdf