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1800 170 170
Demographic Information:
Full Name:
*
Surname:
*
Preferred Name:
Date of Bith:
*
Full Address:
Home Phone:
Mobile Phone:
*
Preferred Contact Phone:
Mobile
Home
Email:
*
Emergency Contact Name:
Emergency Contact Number:
*
Medicare /DVA Details:
Medicare Card Number:
*
Ref No:
*
Expiry Date:
DVA Card Number:
Expiry Date:
Type of Card:
Gold
White
Lilac
Orange
Employment Information:
Occupation:
Level of exertion at work:
If moderate or heavy exertion, please plan on not working the next 4-5 days.
Preferred Vasectomy Location:
Ex: Kingston 4114
Preferred Scheduled Date:
Medical Information:
Have you ever had an allergic reaction to any medications?
No
Yes
Do you take any prescribed Medication:
No
Yes
Have you ever had any of these operations?
Hernia surgery as an infant or child
Yes
No
Hernia surgery as an adult
Yes
No
Surgery as a child for undescended testicle
Yes
No
Surgery for a torsion or twisted testicle
Yes
No
Removal of testicle
Yes
No
Prior Vasectomy or prior vasectomy and reversal
Yes
No
Any other type of Scrotal or testis surgery:
No
Yes
Have you ever had any other operation?
No
Yes
Have you ever had any of these problems?
*
Problems with bleeding or easy bruising
Difficulty getting or maintaining erections
Premature ejaculation
Difficulty reaching a climax
Tendency to get lightheaded or faint when having or witnessing medical procedures or tests.
Herpes
Genital Warts
HIV
Epididymitis
Varicocele
No
Yes
General Practitioner Details:
Name of your family doctor:
Clinic Name:
Clinic Contact Number:
Family Information:
Your Age:
Marital Status:
Married
Single
Partner's full name
Your Partner's permission is not necessary for your vasectomy, but is she aware that you are having one?
No
Yes
May we communicate with her regarding vasectomy scheduling and post vasectomy semen checks?
No
Yes
How you would refer to yourself with respect to your partner:
Husband
Fiance
Boyfriend
Partner
N/A
Your Partner's age:
Number of years with your present Partner:
Number of children you have had with your present Partner:
Total number of children you have had:
Total number of children your present Partner has had:
Age of your youngest child:
13. Were your children all planned?
No
Yes
14. Was your youngest child planned?
No
Yes
Is your Partner pregnant now?
No
Yes
Primary method of birth control over the past few months:
None
Avoidance
Rhythm
Withdrawal
Vaginal (spermicidal cream) cream, foam or film
Diaphragm
Condoms
Birth Control Pills
Depo Shots
Birth Control Patches
Arm Implant
IUD
Other
Referral Information:
What was the primary source of referral to this practice?
Our website
Google search
Word of mouth
Social media
Other
Please Specify:
Confirmation of Preparation for Vasectomy:
I have read and understand my Doctor's Vasectomy Information Page, which includes instructions to be followed before and after the vasectomy:
*
No
Yes
I have watched the Vasectomy Counselling Video Online:
*
No
Yes
I understand that I should not take any aspirin or aspirin-containing compounds for a week prior to my vasectomy:
*
No
Yes
After your procedure, we would like to send you a five question survey via email about your experience.
Your feedback is critical
to our doctor's ability to present ratings to future users "shopping" for a good vasectomy experience. Will you participate?
No
Yes
I consent to receive electronic communication from this practice:
No
Yes
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About Us
Circumcision
Circumcision Info
Circumcision Pricing
Vasectomy Info
Pricing
Contact Us
Locations
Media
Blog
