Vasectomy Registration - Gentle Procedures Vasectomy

Patient Information

Name*

First Last

Date of birth*

Medicare Card Number

(if available)

IRN Number

Medicare Expiration Date

Healthcare Card Number

(if available)

Address*

Residential Address Suburb City State Post Code

Preferred Phone Number*

Email*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Where did you hear about us?

Referring Doctor (if applicable)

Referring Doctor's Name

First Last

Referring Doctor's Address

Suburb City

Family Information

What is your current relationship status?*

Length of relationship:*

Enter “none” if none.

Partner’s Age:

Do you have children together?*

Yes
No

Age(s):*

Enter “none” if none.

Do you have children from a previous relationship?*

Yes
No

Age(s):*

Enter “none” if none.

Does your partner have children from a previous relationship?*

Yes
No

Age(s):*

Enter “none” if none.

Is your partner currently pregnant?*

Yes (If yes, complete delivery date below)
No

Delivery date if partner is pregnant:

Contraception

What method(s) of contraception do you use?*

If "other" please specify method:

Medical History

Please check any of the following that apply to you: (Please tick all that applies)*

If "other" please specify method:

Surgical History

Please check if you have had any of the following:*

Inguinal or sports hernia in the groin area
Previous vasectomy
Vasectomy reversal
Scrotal or testicular surgery (including lowering of undescended testis)
NONE OF THE ABOVE

Medications

Please list any medications you are taking including name and dosage: (including Aspirin, Advil, other anti-inflammatories)*

Enter "none" if none.

Allergies

Please list your allergies*

Enter “none” if none.

Vasectomy Agreement

You must consent to the following:

*

I have read the information on the website regarding no-scalpel vasectomy

*

I understand all the potential complications of the surgery including scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome and late failure.

*

I know I should not drink alcohol for 48 hours before and for 48 hours after the procedure.

*

I know I must not take aspirin (ASA), anticoagulants (warfarin), or anti-inflammatories (NSAIDS) such as ibuprofen, Advil, Motrin, Aleve, etc, 7 days before the procedure and for 2 days after.

*

I have discussed having a vasectomy with my partner and they are supportive of my decision (Please call our office to discuss if this is not the case).