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Welcome to
My Vasectomy Clinics
Vasectomy Centre in your Local Area
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Name
*
Name:
Surname:
Date of Birth:
*
DD slash MM slash YYYY
Mobile Number:
*
Email Address:
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Address: Street Address
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Suburb
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State
*
Postcode
*
Emergency Contact Name:
*
Relation to Patient
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Emergency Contact Number:
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Medicare Card Number:
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Ref No:
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How many biological children you have?
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Do you take any Blood thinner?
*
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Yes
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Have you ever had hernia operation or any operation in genital area as child or adult?
*
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Provisional Vasectomy Date
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Provisional Vasectomy Time
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