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Vasectomy Registration

Vasectomy Registration Marwan Nasr 2018-06-19T10:04:40+00:00

Please complete the registration form below for no-scalpel vasectomy.

We will call you back to confirm your appointment and answer your questions.

Thanks for booking with us.

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?*
- Single
- Common Law
- Married
- Divorced
- Separated
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?*
- Birth control pill
- Condom
- Diaphragm
- Cervical cap
- IUD
- Depoprovera
- Tubal Ligaton
- Rhythm
- Withdrawal
- Other (please specify below)
If "other" please specify method:
Medical History
Please check any of the following that apply to you: (Please tick all that applies)*
- Ache, pressure or pain in the testicle or groin
- Bleeding problems (including family history of it)
- Depression
- Epilepsy
- Hepatitis A, B, C
- Prostatitis
- Diabetes
- AIDS
- Genital warts
- Herpes
- Scrotal or testicular injury or trauma
- Undescended testis
- History of fainting due to medical procedure or injection
- Other (please specify)
- NONE OF THE ABOVE
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, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, advil, voltaren, naproxen 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).
Phone
This field is for validation purposes and should be left unchanged.

Sydney Vasectomy Clinics

Call us : 0490 813 714 | CONTACT US

Medeco Medical Centre
518 High Street
Penrith, NSW 2750

Canterbury Plaza Medical Centre
2 Charles Street, Shop 10
Canterbury, NSW 2193

Fairfield Vasectomy Clinic
41 Court Road
Fairfield, NSW 2165

Jul 13, 2018

by Henry on No-Scalpel Vasectomy

Dr Naresh made me feel very comfortable during the procedure. There was a little bit of pain however it went very well overall. I would recommend to all of my friends who need this done.Thank you

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