Vasectomy

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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Select a clinic*

Ottawa

Cornwall

Please note, Dr Brulotte has a clinic in Cornwall every 3 to 4 weeks. For the next available dates, please contact us: 613-209-4051.

Ottawa appointments are available weekly.

Personal information

Name*

Date of birth*

Do you have a QC or ON health card?*

Health card number*

(4 letters and 8 numbers)

Health card number :*

(10 numbers and 2 letters)

Health card number

Marital status

Length of current relationship (years)

What is your partner's age?

How many children do you have?

What is the age of your youngest child?

Was the most recent pregnancy planned?

What is your current method of contraception?

Please specify;

Contact information

Primary phone*

Other phone

Email*

Address

Physician information

I have a family physician*

Yes

Family physician: First name, Last name

Family physician's phone number

Family physician's fax number

Did he/she refer you?

Yes

Since you do have a family physician, but do not have a referral letter, you give permission to OVIC staff to fax referral request on your behalf to your family physician. Please provide us with your family physician's fax number in the box above. Note, some physicians will still require you to see them for this referral.

Medical history

Have you had any of the following surgeries? If yes, please select all that apply

Hernia

Undescended testicle

Hydrocele