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Canberra Circumcision & Vasectomy Clinic
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Circumcision Clinic Southeast NSW

Circumcision
No-Scalpel Vasectomy
Penile Frenulectomy
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Circumcision
No-Scalpel Vasectomy
Penile Frenulectomy
Contact
About

Vasectomy Registration

Please complete the registration form below for no-scalpel vasectomy.

We will call you back to confirm your appointment and answer your questions.

Thanks for booking with us.

Vasectomy Registration Form

Patient Information
Name*
First Last
Date of birth*
DD slash MM slash YYYY
Medicare Card Number
(if available)
Medicare Reference Number
Medicare Expiration Date
Healthcare Card Number
(if applicable)
Address*
Residential Address Suburb City State Zip Code
Preferred Phone Number*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How did you hear about us?*
- Online / Google
- GP / Doctor's Referral
- Friend / Family Member
- Radio
Referring Doctor (if applicable)
Referring Doctor's Name
First Last
Referring Doctor's Address
Suburb City
Family Information
What is your current relationship status?*
- Single
- Common Law
- Married
- Divorced
- Separated
Length of relationship:*
Enter “none” if none.
Partner’s Age:
Do you have children together?*
- Yes
- No
Age(s):*
Enter “none” if none.
Do you have children from a previous relationship?*
- Yes
- No
Age(s):*
Enter “none” if none.
Does your partner have children from a previous relationship?*
- Yes
- No
Age(s):*
Enter “none” if none.
Is your partner currently pregnant?*
- Yes (If yes, complete delivery date below)
- No
Delivery date if partner is pregnant:
Contraception
What method(s) of contraception do you use?*
- Birth control pill
- Condom
- Diaphragm
- Cervical cap
- IUD
- Depoprovera
- Tubal Ligaton
- Rhythm
- Withdrawal
- Other (please specify below)
If "other" please specify method:
Medical History
Please check any of the following that apply to you: (Please tick all that applies)*
- Ache, pressure or pain in the testicle or groin
- Bleeding problems (including family history of it)
- Depression
- Epilepsy
- Hepatitis A, B, C
- Prostatitis
- Diabetes
- AIDS
- Genital warts
- Herpes
- Scrotal or testicular injury or trauma
- Undescended testis
- History of fainting due to medical procedure or injection
- Other (please specify)
- NONE OF THE ABOVE
If "other" please specify method:
Surgical History
Please check if you have had any of the following:*
- Inguinal or sports hernia in the groin area
- 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)*
Enter "none" if none.
Allergies
Please list your allergies*
Enter “none” if none.
Vasectomy Agreement
You must consent to the following:
*
- I have read the information on the website regarding no-scalpel vasectomy
*
- I understand all the potential complications of the surgery including scrotal hematoma, infection, epididymitis, sperm granuloma, post vasectomy pain syndrome and late failure.
*
- I know I should not drink alcohol for 48 hours before and for 48 hours after the procedure.
*
- I know I must not take aspirin, anticoagulants (warfarin), or anti-inflammatories (NSAIDs) such as ibuprofen, advil, voltaren, naproxen etc, 7 days before the procedure and for 2 days after.
*
- I have discussed having a vasectomy with my partner and they are supportive of my decision (Please call our office to discuss if this is not the case).
Email
This field is for validation purposes and should be left unchanged.

Southern Highlands Bowral Circumcision Centre

Call now: 02 6103 3972 | CONTACT US

Gungahlin General Practice
Gungahlin Square
10 Hinder Street
Gungahlin ACT 2912

Fax: 02 6241 0877

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