Vasectomy Registration

Patient Information
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Healthcare Card Number*
Date of Birth*
Preferred Phone Number*
Alternative Phone Number (such as work phone number)*
Type "N/A" if none
Email*
Occupation*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How did you hear about us?*
Family Doctor (If different from referring doctor)
Family Doctor's Name
First Last
Phone
Surgical History
Please check if you have had any of the following:*
- Hernia
- 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)*
Type "N/A" if none
Sperm Storage
Will you be storing sperm?*
- I will be storing sperm
- I will NOT be storing sperm
Premium Service
Will you be choosing Premium Service? (Strongly Recommended)*
Includes:NO-NEEDLE ANAESTHESIA for your comfort. ALL AFTERCARE SUPPLIES to save you time. FOLLOW-UPS BY PHONE so you don't have to travel back to the clinic.Please see the Vasectomy Fees page for more detail on this $245 optional uninsured service.
- Yes, I would like Premium Service
- No, I do not want Premium Service
Vasectomy Agreement
You must consent to the following:
*
- I have read the information on the website regarding no-scalpel vasectomy.
*
- I understand the potential complications of the surgery including scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome and late failure and have had all questions answered to my satisfaction.
*
- I know I must not drink alcohol for 48 hours before and for 48 hours after the procedure.
*
- I have read the section on "Fees" and understand that while my vasectomy is covered by Saskatchewan Health the vast majority of patients purchase the Premium Package for improved comfort and convenience including the benefits of No-Needle Anesthesia.
*
- 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 understand that if I book my vasectomy and do not show up OR if I cancel my vasectomy with less than two business day's notice OR if I do something I was clearly instructed not to do (ie. Take ASA, NSAIDS or anticoagulants within the previous week) thereby requiring my surgery to be cancelled, I am required to pay a cancellation fee of $245.
Comments
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Vasectomy Registration Online

Vasectomy Registration Form

Patient Information

Family Doctor (If different from referring doctor)

Surgical History

Medications

Sperm Storage

Premium Service

Vasectomy Agreement