IUD Removal

Consent

IUD Removal Consent Form

Equipment List

Chux pads (3)

Exam-room sheet (1 sheet)

Sanitary pad (1)

Speculum (1 each size)

Speculum light (1)

Sponge forceps (1)

Cytobrush (1)

Foxtail swabs (10)

Surgical lubricant (2)

Procedure Note

IUD REMOVAL

Pre-procedure counseling and consent completed, all questions answered.  A timeout was performed and time documented on paper consent form.

The speculum was inserted and the cervix was identified.  The IUD strings were identified and grasped with sponge forceps and the IUD was removed without difficulty.  The patient tolerated the procedure well.  No complications.  IUD inspected by myself and patient, complete IUD and attached strings present.  IUD disposed of appropriately.  Standby present throughout procedure: _.