Intrauterine device (IUD) Insertion/removal/changeover consent

First Name *

Last Name *

Date of birth *

Date of Procedure

Doctor *

Which procedure are you giving financial consent for *

IUD Insertion IUD ChangeoverIUD Removal

Which IUD are you Looking at ? *

MirenaKylenaCopper IUDUnsure to discuss in Consult

VERY IMPORTANT - Do you consent to understanding that neither IUD changeover nor removal procedures will proceed if you have had unprotected sex within the last 7 days *

Financial Consent

Type of Appointment	Fee	Medicare Rebate
Insertion only	$345.00 - $490.00	Eligible Medicare Card Holders $116.45 - $154.35
Removal only	$185.00	Eligible Medicare Card Holders $41.40
Changeover	$425.00 - $570.00	Eligible Medicare Card Holders $116.45 - $154.35

Do you understand that the fees quoted are for IUD related consultations. If you are consulted for unrelated conditions in addition to this procedure your will be charged an additional medicare item number which will have added charges. *

I have read and understood the finances that are related to this procedure *

I have further questions regarding financial section, I would like a specialist admin team member to discuss this with me further prior to my procedure date:

Patients name

Date of procedure

I confirm that I wish tko proceed with this IUD procedure

Signature *

Draw signature|Type signatureClear

Date *