Vasectomy
Online Registration Form
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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 web site.
    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 consultation appointment. Once an appointment is made, we require advance notice of cancellation:
    • 1 week’s notice for a vasectomy appointment or there is a $120 charge

Required Information

*Required fields

Personal Information

Last Name :

*

First Name :

*

Date of Birth :

day month year *

Health Card Number :

*

Version Code ( Ontario ) :

Expiry Date if Applicable : (DD/MM/YY)

Province of Health Card :

*

Name as printed on your Card :

*

Name of local pharmacy :

Telephone number of local pharmacy (including area code) :

- (include area code)

Contact Information

Address Line 1 :

*

Address Line 2 :

City :

*

Province :

*

Country :

*

Postal Code :

*

Home Phone :

- (include area code)*

Work Phone :

- (include area code)

Cell Phone :

- (include area code)

Preferred Phone :

Cell Home Work*

Email Address :
(a private one where we can send confidential info to you…not a work address)

*

Please re-enter your Email Address to confirm:

*

Occupation

Job Title :

*

Description of what you do :

*

Level of exertion at work :

*

Physician Information

Family Physician's Name :
Telephone Number : - (include area code)
I have a Family Physician :
Yes No*
Did your Family Physician refer you? :
Yes No*

(If another physician referred you, please indicate below)
Referring Physician's Name :
Telephone Number : - (include area code)
I was referred by a doctor : Yes No*

Family

Marital Status :

*

Number of Children :

*

Age of youngest child:

* *

Medical History

Have you ever been diagnosed with any medical conditions (including asthma, diabetes, colitis etc.)?

Yes No*

Please describe:

Are you a smoker?

Yes No*

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

Yes No*

Please list all medications:

Are you allergic to any medications?

Yes No*

Please list all medication allergies:

Do you have any problems with local anesthetic (freezing) at the dentist?

Yes No*

Please describe

Do you have any bleeding problems or do you take any medication (like Aspirin or Coumadin) that promote bleeding?

Yes No*

Please describe

Have you ever fainted or do you get queasy/faint with medical things like a blood test?

Yes No*

Please describe

Do you have difficulty getting or maintaining an erection?

Yes No*

Have you ever had surgery to the scrotum or testicles including, but not limited to vasectomy, undescended testicles, torsion of the testicles, hydrocoele, varicocoele, hernia repair in childhood, tumor/cyst,growth in the scrotum or removal of a testicle?

Yes No*

Please describe:

Have you ever had genital herpes or genital warts?

Yes No*

Please describe

Have you ever had a disease that can be transmitted by blood including, but not limited to, hepatitis or AIDS?

Yes No*
Please describe

Have you ever had pain in the scrotum due to epididymitis or other cause?

Yes No*

Please describe

What method of birth control are you using now?

*

My partner is pregnant.

Yes No*

How did you find us?

*

Vasectomy Preparedness

I confirm that I do not want to father any more children in my lifetime.

Yes No *

I have read the information in the ’Information’ section of this web site.

Yes No *

I know I must avoid aspirin, ASA, or any products containing this for 7 days pre-operatively.

Yes No *

I am aware of the restrictions on physical activity for the week following the vasectomy

Yes No *

 
* I confirm that I am the patient whose name appears in the personal information above and that I am filling this registration for myself and not for a husband or partner

 

      

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