Form DHHS4108 "Request and Consent for Levonorgestrel Releasing Intrauterine Device" - North Carolina

What Is Form DHHS4108?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHHS4108 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DHHS4108 "Request and Consent for Levonorgestrel Releasing Intrauterine Device" - North Carolina

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N.C. Department of Health and Human Services
1. Last Name
First Name
MI
Division of Public Health
Women's and Children's Health Section
Family Planning and Reproductive Health Unit
2. Patient Number
3. Date of Birth
(MM/DD/YYYY)
Request and Consent for
Month
Day
Year
Levonorgestrel Releasing
4. Race
American Indian or Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Intrauterine Device
Unknown
White
5. Ethnic Origin
Hispanic Cuban
Hispanic Mexican American
Hispanic Other
Hispanic Puerto Rican
Not Hispanic/Latino
Unreported
6. Gender
Female
Male
7. County of Residence
Voluntary Participation and Confidentiality Statement: Title X services are provided solely on a voluntary basis. Individuals must not
be subjected to coercion to receive services or to use or not to use any particular method of family planning. Acceptance of family planning
services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance from or participation in any other programs
of the applicant. This information is confidential and will be treated as such.
Birth control methods may have good or bad side effects or complications, which may be harmful to me. I have been told that the most
frequent benefits, risks and side effects are those listed below. Others not listed may occur.
Levonorgestrel IUD Use Effectiveness: 99.8 Percent
Benefits
Possible Risks/Disadvantages
Possible Side Effects
1. Highly effective contraception
1. Infections occur within the first few days after
1. Altered menstrual period first few
lasts three to five years depending
Insertion (rarely)
months after insertion
on the IUD brand.
2. IUD may go through the uterus. This is called
2. Gives freedom for greater sexual
perforation.
spontaneity
3. The IUD may come out by itself (expulsion). Use of
3. Cost effective
a backup birth control method would be required for
expulsion.
4. Decreased risk of ectopic
pregnancy
4. Missing IUD threads/strings—your provider can
usually remove an IUD with missing threads in
5. Less blood loss during periods
the office. Rarely, you will need minor surgery to
6. Convenient
remove an IUD with missing threads.
5. No protection from sexually transmitted diseases
including HIV
Contraceptive Technology 20
ed. 2011
th
1. I do not wish to become pregnant now. One benefit of choosing a method of birth control is that I will be better able to delay a pregnancy
until it is desired.
2. All contraceptives offered by this clinic have been explained to me. I may change to another method if medically recommended. Also, I
may stop using a birth control method if I wish to become pregnant. Instructions for the use of my chosen method have been given to me.
3. I understand that to continue the use of the levonorgestrel releasing IUD, I must come to the clinic for my yearly check up. It is my
responsibility to schedule my yearly health check. I also understand it is my responsibility to check for IUD strings monthly and call my
healthcare provider if I am unable to locate the strings.
4. I understand if any of the following danger signs occur severe abdominal pain, unexplained fever or fever after insertion, pelvic pain or
pain during sex, unusual vaginal discharge, genital sores, cannot feel the IUD strings, have severe or prolonged vaginal bleeding, or if
partner has sexually transmitted disease, I know to seek medical attention immediately.
DHHS 4108 (Revised 5/2017)
Family Planning and Reproductive Health (Review 5/2020)
N.C. Department of Health and Human Services
1. Last Name
First Name
MI
Division of Public Health
Women's and Children's Health Section
Family Planning and Reproductive Health Unit
2. Patient Number
3. Date of Birth
(MM/DD/YYYY)
Request and Consent for
Month
Day
Year
Levonorgestrel Releasing
4. Race
American Indian or Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Intrauterine Device
Unknown
White
5. Ethnic Origin
Hispanic Cuban
Hispanic Mexican American
Hispanic Other
Hispanic Puerto Rican
Not Hispanic/Latino
Unreported
6. Gender
Female
Male
7. County of Residence
Voluntary Participation and Confidentiality Statement: Title X services are provided solely on a voluntary basis. Individuals must not
be subjected to coercion to receive services or to use or not to use any particular method of family planning. Acceptance of family planning
services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance from or participation in any other programs
of the applicant. This information is confidential and will be treated as such.
Birth control methods may have good or bad side effects or complications, which may be harmful to me. I have been told that the most
frequent benefits, risks and side effects are those listed below. Others not listed may occur.
Levonorgestrel IUD Use Effectiveness: 99.8 Percent
Benefits
Possible Risks/Disadvantages
Possible Side Effects
1. Highly effective contraception
1. Infections occur within the first few days after
1. Altered menstrual period first few
lasts three to five years depending
Insertion (rarely)
months after insertion
on the IUD brand.
2. IUD may go through the uterus. This is called
2. Gives freedom for greater sexual
perforation.
spontaneity
3. The IUD may come out by itself (expulsion). Use of
3. Cost effective
a backup birth control method would be required for
expulsion.
4. Decreased risk of ectopic
pregnancy
4. Missing IUD threads/strings—your provider can
usually remove an IUD with missing threads in
5. Less blood loss during periods
the office. Rarely, you will need minor surgery to
6. Convenient
remove an IUD with missing threads.
5. No protection from sexually transmitted diseases
including HIV
Contraceptive Technology 20
ed. 2011
th
1. I do not wish to become pregnant now. One benefit of choosing a method of birth control is that I will be better able to delay a pregnancy
until it is desired.
2. All contraceptives offered by this clinic have been explained to me. I may change to another method if medically recommended. Also, I
may stop using a birth control method if I wish to become pregnant. Instructions for the use of my chosen method have been given to me.
3. I understand that to continue the use of the levonorgestrel releasing IUD, I must come to the clinic for my yearly check up. It is my
responsibility to schedule my yearly health check. I also understand it is my responsibility to check for IUD strings monthly and call my
healthcare provider if I am unable to locate the strings.
4. I understand if any of the following danger signs occur severe abdominal pain, unexplained fever or fever after insertion, pelvic pain or
pain during sex, unusual vaginal discharge, genital sores, cannot feel the IUD strings, have severe or prolonged vaginal bleeding, or if
partner has sexually transmitted disease, I know to seek medical attention immediately.
DHHS 4108 (Revised 5/2017)
Family Planning and Reproductive Health (Review 5/2020)
5. I have read the above (or have had it read to me) and have been given the opportunity to ask questions and received answers to my
satisfaction. Being mentally competent, I assume full responsibility and release the local health department, including the attending
clinician, staff and assistants of any and all liability for any adverse effects or pregnancy that may result from my using the method of
birth control provided to me. I have been advised to call the clinic for discontinuation instructions if I choose to stop this method.
6.
I
have been provided information about an emergency number to call after clinic hours or when the agency is closed.
7. I have chosen and requested the levonorgestrel releasing intrauterine device as a method of birth control.
_____/_____/_____
__________________________________________
Date
Signature of Patient
INTERPRETER’S STATEMENT
If an interpreter is provided to assist the individual in choosing her birth control method:
I have translated the information and advice presented orally to the individual to use the above contraception by the person obtaining this
consent. I have also read her the consent form in _______________________ language and explained its contents to her. To the best of my
knowledge and belief, she understood this explanation.
_________________________________________
_____/_____/_____
Interpreter
Date
DHHS 4108 (Revised 5/2017)
Family Planning and Reproductive Health (Review 5/2020)
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