VASECTOMY REGISTRATION FORM

This form is mandatory, even if you’ve already been referred by your family physician. If you have not yet been referred, our office will contact your physician to obtain a referral. Please note that your physician may require that you see him/her for this referral. Referrals for Quebec patients are not required.

If you do not have a family physician, simply complete the following Online Registration form.

Please read all the information provided on this website. If anything is unclear, or if you think you would benefit from a telephone consult with Dr. Brulotte, please indicate so in the registration form below. Our office will contact you within 5 business days to book your vasectomy.

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Registration Form

PERSONAL INFORMATION

SingleIn a relationshipCommon lawMarriedDivorcedSeparated

YESNO

YesNo

YesNo

NoneCondomsBirth control pillIUD (Intra-uterine device)Other

CONTACT INFORMATION

PHYSICIAN INFORMATION

YesNo

YesNo

MEDICAL HISTORY:

YesNo
Hernia Undescended testicleHydrocelePrior vasectomyOther scrotal or testicular surgery

YesNo

YesNo

YesNo

YesNo

YesNo

WeekMonth1-3 Months3+ MonthsI would like to request a specific date, week or month.

CONSENT

Note – You will be asked to sign this consent form at your appointment.

I have reviewed and understand the information found on this website regarding No-needle No-scalpel vasectomy.

I am requesting a vasectomy. This will permanently block the tubes (vas deferens) that carry sperm into my semen.

I know I must avoid aspirin, or aspirin containing products for at least 5 days pre-operatively.

I understand the physical restrictions for the first 7 days.

There is a small chance that the vasectomy will not work.

My semen will be checked after the vasectomy to make sure it worked. It usually takes 3 months and 20 ejaculations for the semen to be clear of sperm. I should use another form of birth control until I get my semen test results. Otherwise, my partner(s) may get pregnant.

I will have local anaesthesia using lidocaine. As far as I know, I am not allergic to lidocaine.

Risks of a vasectomy include, but are not limited to: Infection, bleeding, swelling, allergic reaction, and pain. A small percentage of men may have chronic pain after the procedure, also known as post-vasectomy pain syndrome.

If I have a problem during the procedure, I allow Dr. Brulotte to give me any treatment I need.

By consenting to a vasectomy and accepting the risks outlined above, I release Dr. Brulotte and his associates from liability for time lost from work, salary unearned, and medical expenses incurred to treat complications.

I give full consent for Dr. Marc Brulotte to perform my vasectomy.