Vasectomy

Online Registration Form

BACK TO MAIN MENU

Online Vasectomy Registration

This registration form must be completed by the patient only and may NOT be filled in by a spouse, partner or other person unless the patient is present throughout the process and has read and reviewed all the required information.

 

Here's how it works

  1. Read the Information Section of this website
    Go to: No-Scalpel Vasectomy Information
  2. Fill in the registration form below and click 'Submit'
  3. Our office will phone you within 7 business days to book your appointment. Once an appointment is made, we require advance notice of cancellation:
    • 1 week's notice for a vasectomy appointment or there is a $150.00 charge

Required Information
*required fields

Personal Information

*
*
*
*
*
*

Contact Information

*
*
*
*
*
*
Cell
Home
Work
*

Occupation Information

*
*
*

Physician Information

*
Yes
No
*
Yes
No
(If another physician referred you, please indicate below)
*

Family

*
*
*

Medical History

Are you a smoker? *



Are you on any prescription medications (including inhalers, insulin etc.)? *

Vasectomy Preparedness