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PATIENT CONSENT FOR DEPO-PROVERA
Depo-Provera is a hormone used to inhibit ovulation. As a form of birth control, it is 99.7% effective.
Depo-Provera is given by intramuscular injection and last for about twelve weeks. To be effective, an
injection must be given every twelve weeks. Depo-Provera may be given to breast-feeding women
when six weeks post partum or when not breast-feeding within five days post delivery.
For the first-time user, Depo-Provera should be given within five days of the start of menses. No back-
up contraceptive method is needed if administered within these schedules.
Potential side effects from the injection include :
- At the end of the twelve weeks after the injection, it may take from several months to a year to get
pregnant.
- Using Depo-Provera while pregnant may cause birth defects.
- Depo-Provera should not be used in the presence of serious active liver disease, unexplained vaginal
bleeding, known or suspected breast cancer, blood clots in the legs, lungs or eyes ...
- Depo-Provera may cause a change in periods, including bleeding more days than usual, spotting
between periods or no periods. These changes are common, particularly in the first six months of
use.
- If a health care provider is seen for any reason, he/she should be informed of your Depo-Provera
use.
- Women who use Depo-Provera may have a decrease in the amount of mineral stored in their bones.
Most of the mineral comes back as soon as the Depo-Provera is stopped.
- Minor side effects may include nausea, breast tenderness, weight gain (a few pounds each year),
headaches, nervousness, dizziness, cramping, weakness or fatigue, or decrease sex drive. These
side effects may decrease over time.
- Studies have found that women who used Depo-Provera for contraception had no increased overall
risk of cancer of the breast, ovary, uterus, cervix, or liver. Women under 35 years of age whose first
exposure to Depo-Provera was within the previous four years, may have a slightly increased risk of
breast cancer similar to that seen with oral contraceptives.
I have read and do understand the above side effects and complications of using Depo-Provera
injections. Alternatives forms of birth control were discussed along with the risks and benefits of each.
I agree to informn my doctor promptly of any side effect of this medication.
| ______________________ | ________________________ | __________________________________ |
| Date | Patient Name | Patient Signature |
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The undersigned physician has gone over this consent form with the patient and answered any questions
and explained any terms that were unfamiliar to the patient.
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| ______________________ | | __________________________________ |
| Date | | Physician's Signature |
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