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Northeast iowa community action corporation

FAMILY PLANNING PROGRAM
INFORMED CONSENT FOR CONTRACEPTIVE METHODS
(Prescription & Non-Prescription)
ORAL CONTRACEPTIVES
I have chosen oral contraceptives as my method of contraception. I have been provided counseling
and written information regarding the benefits and risks, effectiveness, potential side effects,
complications, and danger signs of oral contraceptive use. I have been given the opportunity to ask
questions and I understand the information that has been provided to me.
_________________________________

DEPO-PROVERA
I have chosen Depo-Provera as my method of contraception. I have been provided counseling and
written information regarding the benefits and risks, effectiveness, potential side effects,
complications, and danger signs of Depo-Provera. I have been given the opportunity to ask questions
and I understand the information that has been provided to me.
_________________________________

NUVA RING
I have choosen the Nuva Ring as my method of contraception, I have been provided counseling and
written information regarding the benefits and risks, effectiveness, potential side effects,
complications, and danger signs of Nuva Ring. I have been given the opportunity to ask questions
and I understand the information that has been provided to me.
_________________________________

BARRIERS (Condoms, Foams, or Diaphragm)
I have chosen to use a barrier as my method of contraception. I have been provided counseling and
written information regarding the benefits, risks, effectiveness, potential side effects, and
complications related to the use of this method. I have been given the opportunity to ask questions
and I understand the information that has been provided to me.
_________________________________
INTRAUTERINE DEVICE (IUD)
I have chosen the Intrauterine Device (IUD) as my method of contraception. I have been provided
counseling and written information regarding the benefits and risks, effectiveness, potential side
effects, complications, and danger signs of the IUD. I have been given the opportunity to ask
questions and I understand the information that has been provided to me.

_________________________________

IMPLANON
I have chosen the Implanon as my method of contraception. I have been provided counseling and
written information regarding the benefits and risks, effectiveness, potential side effects,
complications, and danger signs of the Implanon. I have been given the opportunity to ask questions
and I understand the information that has been provided to me.
_________________________________

EMERGENCY CONTRACEPTION (PLAN B)
I have requested Plan B for emergency contraceptive use. I have been provided counseling and
written information regarding the benefits and risks, effectiveness, potential side effects,
complications, and danger signs of using Plan B. I have been given the opportunity to ask questions
and I understand the information that has been provided to me.
_________________________________

ORTHO EVRA “The Patch”
I have chosen Ortho Evra transdermal system as my method of contraception. I have been provided
counseling and written information regarding the benefits and risks, effectiveness, potential side
effects, complications, and danger signs of Ortho Evra transdermal system use. I have been given
the opportunity to ask questions and I understand the information that has been provided to me.
_________________________________
NATURAL FAMILY PLANNING (CycleBeads) OR FERTILITY AWARENESS METHOD
I have chosen to use Natural Family Planning for Fertility Awareness as my method of
contraception. I have been provided counseling and written information regarding the benefits,
risks, effectiveness and complications related to the use of this method. I have been given the
opportunity to ask questions and I understand the information that has been provided to me.
_________________________________

Source: http://neicac.org/forms/fpforms/InformedConsentForContraceptionEnglish.pdf

Modified nitrocefin-edta method to differentially quantify the induced l1 and l2 β-lactamases in stenotrophomonas maltophilia

Letters in Applied Microbiology ISSN 0266-8254Modified nitrocefin-EDTA method to differentially quantifythe induced L1 and L2 b-lactamases in StenotrophomonasmaltophiliaR.-M. Hu1, K.-H. Chiang2, C.-W. Lin2 and T.-C. Yang21 Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan2 Department of Medical Laboratory Science and Biotechnology, China Medical University, Taichu

Extracorporeal membrane oxygenation for pandemic (h1n1) 2009

Suggested citation for this article: Firstenberg MS, Blais D, Louis LB, Stevenson KB, Sun B, Mangino JE. Extracorporeal membrane oxygenation for pandemic (H1N1) 2009 [letter]. Emerg Infect Dis. 2009 Dec; [Epub ahead of print] To the Editor : As the world struggles with the challenges of influenza A pandemic (H1N1) 2009, it is clear that treatment options for critically ill infected patient

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